Primary surgery for cleft lip, alveolus, and palate is only the beginning of management for this condition, because the congenital malformation and the scars of corrective surgery during infancy affect the physiological development of the skeleton and the soft tissue. Once the patient has stopped growing, therefore, secondary maxillomandibular malformation is frequent in these patients. The most frequent skeletal malformations in secondary cleft lip and palate are hypoplasia and malposition in the three planes of the superior maxilla space. In these cases, combined orthodontic and surgical treatment is necessary; of the various techniques available, Le Fort I osteotomy is the one most indicated for repositioning of the maxilla. Although this technique is now standardized to correct the simple maxillo-mandibular malformation, in the case of secondary malformation in the cleft lip and palate, modifications are necessary in the surgical technique to ensure the best esthetic and functional result and to reduce the possibility of relapse. After 20 years’ experience in the treatment of secondary skeletal malformation in cleft lip, alveolus, and palate, a critical review is made of the different steps of planning and performing Le Fort I osteotomy in these patients.