Objective: The pharyngeal flap is the most frequently used surgical treatment in the management of velopharyngeal insufficiency; however, recent concerns over poor post-operative outcomes and high complication rates have made the relevance of this procedure increasingly debatable. To evaluate speech outcomes and complication rates following this procedure, a non-randomized retrospective cohort study of over 220 consecutive pharyngeal flap surgeries was conducted. Methods: A database review was undertaken of all pharyngeal flap procedures completed between January 2000 and April 2006 at a tertiary, pediatric craniofacial center. Main outcome measures included perceptual speech parameters, nasality, immediate post-operative complications, and obstructive sleep apnea development. In addition, post-operative complications such as unanticipated bleeding, infection, and obstructive sleep apnea were evaluated as well. Results: Of 222 consecutive pharyngeal flap patients, 150 (68.57%) underwent both pre- and post-operative speech evaluation. Patient mean age at surgery was 6.4 years (range: 3.1 to 17 years). One hundred and twenty-four post-operative patients (82.67%) demonstrated no or mild hypernasality (none: 67.33%, mild: 15.33%). Eight patients (5.33%) presented with mild post-operative hyponasality. Twenty-two patients (14.67%) demonstrated residual VPI. Post-operative complications were rare in this cohort. Twelve patients (8.00%) required supplemental oxygenation for limited desaturations, and 3 patients (1.35%) demonstrated significant post-operative bleeding. Five patients (3.33%) demonstrated positive findings of OSA at 6 months or greater post-pharyngeal flap. Conclusions: Following thorough pre-operative evaluation and planning, pharyngeal flap surgery reliably reduces velopharyngeal insufficiency without significant risk of post-operative complication.