**Purpose:** Facial differences associated with cleft lip are often stigmatizing and negatively impact quality of life. However, little is known regarding patients' responses to societal expectations of appearance, or how these responses may impact surgeon-patient communication. We hypothesized that children who want revision surgery may fail to communicate appearance-related concerns secondary to societal pressures to "save face," which is a sociologic phenomenon employed to minimize stigma.

**Methods:** Patients with cleft lips at least 8 years of age (n=31) were purposively sampled for semi-structured interviews. After verbatim transcription, first cycle coding proceeded with a semantic approach, which revealed patterns that warranted second cycle coding. We utilized an eclectic coding design to capture deeper meanings in thematic analysis. Additionally, survey data from a separate study were examined to evaluate participants' interest in improving appearance.

**Results:** Three major themes emerged, all of which reflected a desire to "save face" when interacting with society: 1) Cultural mantras, which included societal mottos that minimized the importance of appearance; 2) Toughening Up, wherein the participants downplayed the difficulty of having a cleft; and 3) Deflection, wherein the participants took pride in facial features unrelated to their clefts. Despite these efforts to "save face," 78% of participants expressed interest in improving their appearance in the separate survey data.

**Conclusions:** Children with cleft lips defensively try to "save face" when interacting with society by depreciating appearance, making light of clefts, and focusing on non-cleft related features. Paradoxically, most of these children desired improvement of their appearance in an earlier survey. These defensive strategies could negatively impact surgeon-patient communication and result in underutilization of revision surgery. As such, surgeons should identify strategies that allow patients to voice appearance-related concerns, despite the pressure to "save face" in front of others.
