ObjectiveVelopharyngeal insufficiency (VPI) poses challenges for normal speech production, often necessitating surgical intervention. Determining optimal candidates for surgery remains complex and requires a nuanced understanding of underlying anatomic factors contributing to VPI. This study aimed to identify anatomic predictors that drive surgical recommendations for VPI.DesignProspective observational cohort study.SettingPediatric tertiary care hospital.MethodsMagnetic resonance imaging data were acquired from 150 children (aged 4-17) to identify anatomic predictors of VPI and surgical need. Fourteen velopharyngeal variables were measured in the oblique coronal and midsagittal imaging planes. Calculations included differences in levator veli palatini (LVP) muscle angles of origin, mean extravelar length, differences between left and right extravelar segments, the VP Needs ratio, and a newly developed LVP ratio. Multivariate logistic regression models with k-fold cross validation were utilized to identify anatomic profiles predictive of VPI and receiving a surgical recommendation.ResultsThe models demonstrated high accuracy, sensitivity, and specificity. Among anatomic variables, the LVP ratio emerged as the strongest determinant of surgical need (β = 11.256,