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Objectives/Hypothesis To find an anatomical measurement of the cleft palate (or a calculated parameter) that predicts the occurrence of velopharyngeal insufficiency (VPI) after palatal cleft repair. Study Design Retrospective cohort study. Methods Charts were reviewed from cleft palate patients who underwent palatoplasty by the Von Langenbeck technique for isolated cleft palate or Bardach two-flap palatoplasty for cleft lip-palate. Seven anatomical cleft parameters were prospectively measured during the palatoplasty procedure. Three blinded speech–language pathologists retrospectively scored the clinically assessed VPI at 4 years of age. The recommendation of pharyngoplasty was also used as an indicator of VPI. Results From 1993 to 2008, 67 patients were enrolled in the study. The best predicting parameter was the ratio a/(30 − b1), in which a is defined as the posterior gap between the soft palate and the posterior pharyngeal wall and b1 is the width of the cleft at the hard palate level. An a/(30 − b1) ratio >0.7 to 0.8 is associated with a higher risk of developing VPI (relative risk = 2.2–5.1, sensitivity = 72%–81%, P