A competent velopharyngeal mechanism is important for the production of normal speech, and the secondary procedure of a posterior pharyngeal flap (PPF) may be necessary in some patients to achieve this goal. A number of complications have been described in the literature following pharyngeal flap surgery. The purpose of this study was to examine short- and long-term complications after PPF surgery, and in particular the incidence and the end effect of nocturnal respiratory obstruction (NRO). All PPFs over a 17-year period performed at one institution and by the same surgeon were examined retrospectively. All medical records from the Commission of Handicapped Children of patients who had a PPF were reviewed. Patients with NRO were identified clinically, and sleep studies were administered with two or more of the clinical triad. During a 17-year period, 111 patients underwent a PPF to treat velopharyngeal incompetence. Twelve patients were identified with a syndromic association in addition to a clefting disorder, of which most (N=9) consisted of Pierre Robin syndrome. The median age at PPF performance was 6.0 years and the average follow-up was 7.4 years. The early postoperative complication rate was 10%, including a 7.2% incidence of respiratory obstruction and 0.9% postoperative bleeding. Twenty-one patients (19%) had late complications or unsatisfactory results. Twelve patients (10.5%) developed NRO, and patients with Pierre Robin syndrome were particularly prone—4 of 9 patients developed this complication. Nine of 12 patients with NRO had sleep studies performed with a minimum interval of 6 months postoperatively. Eight of the nine studies were normal. Of the NRO group, 3 patients had takedown of their PPF, including the patient with an abnormal sleep study. All 3 patients improved markedly and none developed recurrence of velopharyngeal insufficiency. NRO is not an uncommon finding in PPF patients, but NRO does not necessarily imply the presence of obstructive sleep apnea. The consequences of persistent NRO over the long term deserve further study.