Upper airway obstruction after superiorly based pharyngeal flap procedures for the treatment of velopharyngeal insufficiency is described in this series of 32 flaps performed in 29 patients at our institution between 1979 and 1993. A high incidence of upper airway obstruction symptoms (38%) occurred in the early postoperative period but resolved in all but 2 patients within 5 months. None of the patients required flap revision or other procedures for relief of upper airway obstruction. Velopharyngeal insufficiency was improved or completely eliminated in 87% of patients. Significant residual velopharyngeal insufficiency in 13% of patients was treated successfully in all flap revision cases. Race, gender, age at closure, and associated craniofacial anomalies did not correlate with upper airway obstruction or with the efficacy of treatment for velopharyngeal insufficiency. However, patients with transient postoperative upper airway obstruction were only half as likely to suffer residual postoperative velopharyngeal insufficiency. The inverse relationship between velopharyngeal insufficiency and upper airway obstruction (p = .008) suggests that the surgeon may sometimes need to accept some transient upper airway obstruction to achieve correction of velopharyngeal insufficiency.