Little outside my scope of practice--I don't do clefts anymore.
I would imagine with the primary palate that far displaced anteriorly that it will need to be separated from the nasal tip first before anything can be done.
The question is how to reconstruct that defect before even considering the lip and palate. With a lack of skin to begin with in these bilateral clefts, finding new skin for reconstruction will be difficult at best. Obviously rotating it in would be the best option, but from the picture, I have a hard time seeing that there is enough to do so.
I have tried several things to reconstruct the columella when skin is removed and I've never been happy with much. The best match I've found is in helical cartilage composite graft from the ear--the helical rim graft with associated skin is a pretty good match--but that graft is very difficult to keep alive.
tough case that I probably can't help much with. Sorry.