The primary goal of cleft palate repair is to create an anatomically and functionally intact palate while minimally affecting maxillary growth and development. In order to produce normal speech, a child must have velopharyngeal competence, defined as the ability to completely close the velopharyngeal sphincter that separates the oropharynx and nasopharynx. The absence of this ability, termed velopharyngeal insufficiency (VPI), is seen in a wide range of patients following primary cleft palate repair. This article discusses patient assessment, treatment options, and the surgical management of VPI. Recent trends and future directions in management are also presented.