**2. Primary or secondary rhinoplasty**

Primary rhinoplasty means performing rhinoplasty simultaneously with repair of cleft lip and secondary rhinoplasty means performing rhinoplasty at an early age i.e. during school going age(5-6 years), early adolescence (10-12 years) or later on in life (above 16 yrs. in women and age 18 yrs. in men). But as a working diagnosis, primary rhinoplasty in adults with CLND means the first attempt of surgical intervention on the nose and secondary rhinoplasty means revision rhinoplasty or second operation on the nose.

The best time to attempt correction of CLND is still controversial. With improvement in cleft lip surgery, there is an increasing interest for correction of the nose at the time of lip repair. Some authors strongly recommend a primary rhinoplasty and believe if the procedure is performed correctly it does not adversely affect the growth of the paranasal region. Primary rhinoplasty improves nasal symmetry in patients with unilateral cleft lip deformity. This does not exclude the possibility of later revisional surgery although there is tendency to doing an appropriate primary repair of cleft lip deformity but the fact is, small defects that are left after primary repair are amplified with the growth process and affect adjacent structures. It is become clear that primary and secondary rhinoplasty at the same time of lip repair or at age 7-8 can lead to some kind of deformities in adulthood. The adult deformity is related not only to the original embryological mesodermal deficiency and diminished growth potential, but also to the pattern of primary surgery, the degree of interceptive surgery during growth and the level of orthodontic skill practiced within a particular treatment. In our center most cases are referred for primary rhinoplasty in adulthood [3-9].
