Oral and maxillofacial surgery approaches and techniques are important considerations in the comprehensive management of cleft nasal deformities. Establishing a proper bony base for the soft tissues can involve secondary procedures such as alveolar cleft grafting and orthognathic surgery. The cleft deformity itself, but particularly previous surgery, usually dictate modifications of orthognathic surgery techniques. Distraction osteogenesis potentially allows for earlier intervention as well as more extensive bony changes with decreased surgical risk.