Fig. 2

A Unilateral complete cleft lip and palate. Red circle identify the critical transition areas between cleft alveolus and primary palate, between primary and secondary palate and between hard and soft palate. Incision lines on the medial side of the cleft in yellow for the extended Vomer flap that includes the mucoperiosteum of the premaxilla and extends to the buccal side of the alveolar cleft. The buccal part of the alveolar cleft and anterior part of the nasal floor had been already closed during lip repair. B Mobilization of the mucoperiosteum of the premaxilla and the vomer towards the lateral edge of the cleft. Increased mobility is gained by subperiosteal dissection in cranial direction. C Incision line on the lateral side of the cleft extending to the buccal side of the closed alveolar cleft. D Mobilisation of the lateral mucoperiosteum of the palatal bone for at least 5 mm. E Preparation of back-and-forth sutures that unite the periosteal surfaces of the of the medial mucoperiosteum of the premaxilla / vomer with the lateral mucoperiosteum of the palatal bone. F Upon activation a safe overlap of at least 2–3 mm between the two periosteal surfaces should be achieved. G After 3 months, the residual cleft soft palate is addressed with a typical Veau incision (in yellow) extending at least 5 mm beyond the border between the soft and the hard palate, making sure, that enough mucoperiosteum overlying the hard palate is involved. H Elevation of the mucoperiosteum on the cleft side has to be done carefully with blunt preparation through the scar tissue of the former vomer flap bridging the ledge of the palatal bone and the vomer / contralateral palatal bone. I Release of the false insertion of the palatal muscles and reconstruction of the muscular sling is done in typical manner after mobilization and suturing of the nasal mucoperiosteal layer. Bilateral excision of small wedges (in yellow) of the palatal mucoperiosteum at the anterior medial flap egdes. K Medialization of the palatal flaps for reconstruction of the oral layer with simultaneous “push back” through the VY elongation