Phenotypic severity dictates the timing and type of surgical intervention required. Mandibular distraction in children without respiratory and feeding difficulties remains controversial with regard to long-term mandibular growth outcomes and reducing surgical burden. Early mandibular distraction does not obviate secondary orthognathic surgery at skeletal maturity; it provides improved functional, aesthetic, and psychosocial outcomes, at least in the short term. Costochondral rib grafting for Pruzansky type IIB and III mandibles can produce reliable results, especially when combined with subsequent mandibular distraction. Secondary 2-jaw orthognathic surgery plus genioplasty at skeletal maturity benefits from improved bone volume from prior mandibular distraction.