The efficacy of the pharyngeal flap for treatment of refractory velopharyngeal insufficiency (VPI) is questionable. The present series reviews patients with refractory VPI who were managed with a combined Furlow palatoplasty (FP) and a sphincter pharyngoplasty (SPP). Methods: All patients underwent a preoperative evaluation consisting of 1) perceptual speech assessment (scale 1 to 12); 2) nasendoscopy; 3) videofluoroscopy. Patients were categorized as Group 1 ("Black Hole") if lateral wall motion were graded as 1 to 2 over 5 and/or their velopharyngeal gap were 7mm or greater. Patients who had failed pharyngeal flaps were categorized as Group 2. Results: Thirteen patients were included in the study. The degree of lateral wall motion was 1 to 2 in 10 patients. The VP gap on phonation was greater than 7 mm in 7 of 10 patients. in Group 1, and 3-7 mm in Group 2. Mean nasality ratings were 10.2 preoperatively, and 1.8 following FP and SPP (p<.001). Conclusions: The FP alone has been shown to be inadequate to correct severe cases of VPI in which there is a large velopharyngeal gap with minimal lateral wall motion. The addition of a SPP is an effective adjunct to the sphincteric design of the FP.