This patient previously had a complete cleft of the left lip and nose repaired overseas as a baby. The nasal deformity of a cleft lip is one of the most difficult types to correct and the most challenging problem in rhinoplasty. The asymmetry is usually so severe that it is difficult to completely correct but improvements can be achieved. These patients frequently need rib graft cartilage to rebuild the nose. In this case rib graft was not needed because the spetal cartilage provided enough material to address the nasal symmetry and form and more importantly to improve breathing.