**2. Surgical strategy of palate repair approaching each anatomical and pathological abnormality**

The concept of our strategy for CP repair was to approach each anatomical and pathological abnormality that may cause postoperative velopharyngeal incompetence (VPI): short palate, asymmetric palate, insufficient velar elevation, and a midline defect of the velum, to establish CP repair that can ensure VP closure (**Table 1**) [2]. The above factors were identified based on our experiences during the treatment of persistent VPI after CP repair. Therefore, our CP repair consisted of (1) presurgical orthopedics using Hotz's plate as much as possible to minimize the cleft space, (2) modified V-Y palatoplasty, allowing conservation of the periosteum in the anterior part of the maxilla, minimizing maxillary growth disturbance, (3) lengthening of the nasal mucosa using a large Z-plasty and a free mucosal graft, (4) muscular reconstruction producing a symmetrical levator sling and pharyngeal arch, and (5) two-layered suture of the palatal muscles.



**Table 1.** Our surgical strategy for palatal repair approaching each anatomical and pathological abnormality and possible causes of VPI [2].
