The typical result which we desire to gain after an operation for harelip is a symmetrical appearance of lip and nose, and a normal contour and projection of the parts as seen from the front and in profile. The cicatrix should be practically invisible, and the red margin of the lip continuous throughout. Unfortunately, however, in many cases these results are not easily attainable. The tip of the nose tends to become drawn down and depressed, especially when in double harelip the philtrum is poorly developed, or when a mistaken attempt is made to incorporate it between the segments of the lip. This stunted but thickened columna encroaches on and obstructs the anterior nares, whilst in unilateral cases the aperture on the affected side is apt to become dilated and distended from the absence in some instances of the osseous floor, but also from subsequent cicatricial contraction of the previously divided bands between the cheek and maxilla. The behaviour of young cicatricial tissue, moreover, is not always the same. In some young and feeble children it remains vascular for a long time, and at first tends to stretch and become more evident;[100] subsequently contracting, it may leave an indurated cord-like ridge. In addition to this, a longitudinal contraction takes place in direct proportion to the thickness of the cicatrix, reducing the length of the scar and the depth of the lip, thus bringing about the 𝖵-shaped notch in the lip margin, and assisting in the dilatation of the nostril. In double harelip, where the os incisivum has been removed, it has already been mentioned that the upper lip sinks back, the lower lip projects forwards, and the profile resulting therefrom becomes very unsightly (Fig. 75). [Illustration: FIG. 75.—Profile of a case of double harelip after operation with removal of the os incisivum, showing the falling in of the upper lip and the prominent projection of the lower. (_Coles._)] Many of these defects may be remedied by subsequent treatment. I am frequently in the habit of advising and practising secondary operations for the improvement of the facial expression in young children and adults presenting the unsatisfactory cicatrices detailed above. The operation comprises not only the removal of scar tissue, but also the obliteration of the 𝖵-shaped notch, elevation of the depressed nose, and the diminution in size, if necessary, of the nasal aperture. For a simple 𝖵-notch without other complications, I have sometimes made use of Nélaton’s operation (Fig. 48) with most satisfactory results.