INTRODUCTION: Children with cleft palate with or without the cleft lip are predisposed to velopharyngeal dysfunction and the perceptual phenomenon of hypernasality. Researchers estimate that roughly 30% of children with cleft palate will have hypernasality during speech. Research also indicates that children with a history of cleft palate are predisposed to obstructive sleep apnea (OSA). Typical speech surgeries include dynamic sphincter pharyngoplasty, posterior pharyngeal flap and, for minor velopharyngeal gaps, fat grafting to the posterior pharyngeal wall. Dynamic sphincter pharyngoplasty and posterior pharyngeal flap, while effective at decreasing hypernasality, are known to exacerbate obstructive sleep symptoms. These findings lead to the conundrum of how one successfully manages velopharyngeal dysfunction without causing or worsening obstructive sleep apnea in this population. Therefore, we are in need of an operation that effectively decreases hypernasality and overcomes large velopharyngeal gaps, while mitigating the occurrence of obstructive sleep apnea. We propose that palatal lengthening with buccal myomucosal flaps is the solution to this problem. METHODS: The charts of patients with large velopharyngeal gaps and moderate-to-severe hypernasality that underwent palatal lengthening with bilateral buccal myomucosal flaps between 2016 and 2019 were reviewed in a retrospective fashion. Inclusion criteria include a history of cleft palate or another diagnosis that predisposes to hypernasality, and at least 1 postoperative speech evaluation with nasometry. All patients were administered the Picture Cued Subtest and received a perceptual rating from the craniofacial speech-language pathologist. Patients were seen preoperatively for a perceptual speech evaluation, standardized articulation testing (as needed), nasometry, and nasopharyngoscopy. Postoperatively, patients were followed at 6-month intervals during which each patient participated in a perceptual speech evaluation, standard articulation testing (as needed), and nasometry in order to better assess resonance changes over time. Ten patients were enrolled in the study, but only 9 met the inclusion criteria, as one patient was excluded for lack of a postoperative speech evaluation. RESULTS: Nasalance is a nasometry score expressing a ratio of nasal-to-total (nasal plus oral) sound energy, and is reported as percentage. Our study findings indicate that most patients had the same abnormal Nasalance score 6 months postoperatively as they did preoperatively. However, at the 12-month postoperative evaluation, 89% of patients (n = 8) had nasometry scores that improved to normal resonance. The one patient with abnormal Nasalance scores carried a diagnosis of 22q11.2 deletion syndrome. Patients who underwent a third postoperative evaluation continued to demonstrate a decrease in hypernasality and began to have Nasalance scores in the hyponasality range. In addition, all patients with OSA reported no worsening in their obstructive symptoms, as indicated by stable CPAP settings. CONCLUSIONS: Palatal lengthening with bilateral buccal myomucosal flaps improves hypernasality over time, with the greatest benefit seen at the 12-month postoperative nasometry evaluation. This surgical technique does not appear to alter the OSA status of patients thus eliminating the need for supplemental oxygen, or CPAP postoperatively.