BACKGROUND A systematic review was conducted to compare the speech outcomes and fistula rates following repair of the cleft palate with Furlow double-opposing Z-plasty and straight-line intravelar veloplasty techniques. METHODS A systematic search of the English literature published in the MEDLINE, Ovid, and Embase electronic databases was performed using the following keywords: "cleft palate," "intravelar veloplasty," "velopharyngeal insufficiency," and "speech outcome." The exclusion criteria were as follows: syndromic patients, no description or poor description of the technique used, data not stratified by cleft palate type, two-stage cleft palate repair, average age at repair younger than 9 months or older than 18 months, and age at the last follow-up younger than 4 years. Statistical analysis was used to compare the rate of secondary operations and the incidence of velopharyngeal insufficiency. RESULTS Twelve studies satisfied the inclusion criteria. In the isolated cleft palate group, the mean failure rates were 9.7 and 16.5 percent for Furlow double-opposing Z-plasty and straight-line intravelar veloplasty closure, respectively. In the unilateral cleft lip-cleft palate group, the mean failure rates were 11.1 and 17.1 percent for Furlow and straight-line intravelar veloplasty closure, respectively. The difference in the odds of requiring secondary surgery in the straight-line intravelar veloplasty repair group versus the Furlow group was statistically significant (p=0.03) in unilateral cleft lip-cleft palate. CONCLUSIONS This systematic review indicated an increased incidence of velopharyngeal insufficiency as revealed by higher odds of secondary operations in the straight-line intravelar veloplasty repair of unilateral cleft lip-cleft palate when compared with Furlow Z-plasty.