PurposeResidual cleft nasal deformities after initial cleft repair can have long-term cosmetic and psychological impact on patients. The authors describe a novel technique of an alar composite graft for patients with cleft lip and/or palate and assess the surgical outcomes with respect to symmetry of individual anatomical components. Materials and methodsThis was a retrospective study of patients with a history of cleft lip/palate who underwent rhinoplasty with alar composite graft placement by the senior author from March 2014 to January 2021. Patients who had high-quality pre-operative and postoperative 3D imaging were included. Patient age, sex, surgical history, cleft side, cleft details, and operative details were recorded. The primary operative technique includes the following: 1) Weir and sill excision at the donor side, 2) composite graft harvest, 3) Weir and sill incision at the recipient side, 4) graft placement, 5) closure of the incision sites. Three-dimensional imaging was obtained pre-operatively and postoperatively using Vectra M3 3D Imaging (Canfield Imaging System, Fairfield, NJ). Linear and surface area measurements were made on donor and recipient sides. The difference in measurements was calculated to analyze the degree of similarity across sides, and this difference was compared pre-operatively to postoperatively.1,2 Symmetry of the patient's nostrils and overall nasal symmetry was compared pre-operatively and postoperatively using root-mean-square deviation (RMSD), with smaller values indicating more symmetry. Differences between preoperative and postoperative measurements were calculated with a paired T-test. ResultsOut of 10 patients undergoing the surgery, 8 were able to be included in this study. On lateral view, the donor and recipient sides were more similar postoperatively compared to pre-operatively with respect to lateral alar-columellar disproportion (1.040 versus 3.324, P = .005) and nostril area (0.466 versus 1.065, P = .001) . On basal view, postoperative results showed more similar measurements comparing the donor and recipient sides in nostril height (1.461 versus 3.542, P = .012), nostril width (0.956 versus 2.222, P = .033), nasal dome height (1.597 versus 3.822, P = .024), and nostril surface area (0.188 versus 0.531, P = .015). On symmetry analysis, the overall external nose was more symmetrical after placement of the alar composite graft (1.094 vs 1.772, P = .015). ConclusionCleft lip and palate can cause significant asymmetry related to the nostrils, ala, and overall appearance of the nose. The alar composite graft is a useful technique to improve symmetry over a wide range of dimensions on lateral, basal, and frontal views.