Background To review recent advances in pharyngeal modification procedures for the treatment of velopharyngeal insufficiency (VPI) in patients with cleft palate after primary repair. In addition, we discuss some of the advantages and disadvantages of the various pharyngoplasty techniques, as well as their safety and efficacy. Methods A review of frequently used pharyngeal modification techniques in correction of VPI was performed, and their advantages and disadvantages are outlined. Several techniques in pharyngoplasty most recently described in the literature are compared and contrasted. Results The goal of surgical pharyngeal modification procedures is to correct the abnormal failure of velopharyngeal closure. Multiple techniques used in VPI surgery have proven to be effective. They have similar adverse effect profiles, but what distinguishes them is likely their effectiveness in cases of severe VPI. Conclusions Velopharyngeal insufficiency is a problematic issue both for the patient and the treating surgeon. The negative effect of VPI on patients' quality of life has long been known, and over the years numerous techniques have been described to correct or improve this problem. Pharyngoplasty and pharyngeal flap or combination procedures are most effective in cases of severe VPI.