ObjectiveTo investigate whether differences in early cleft care increase risk of velopharyngeal insufficiency (VPI) after maxillary advancement.DesignRetrospective cohort study.SettingLarge pediatric tertiary care hospital.Patients/ParticipantsAdolescents and young adults (AYAs) with cleft palate (∓cleft lip) who underwent maxillary advancement between 2008 and 2019.Interventions/ComparisonsInitial palate repair at a different institution (early care elsewhere, ECE) versus care at a single institution (consistent care, CC).Main Outcome MeasuresPost-maxillary advancement VPI.ResultsOne-hundred seventy-eight AYAs underwent maxillary advancement, 74 in the ECE group and 104 in the CC group. The ECE group was more likely to be internationally adopted (34% versus 4%), to have a history of VPI surgery (54% versus 32%) and to be older at time of palate repair (mean 25 versus 16 months). Of anatomical measures, only velar length differed, with the ECE group tending to have a shorter velum (mean 26 mm versus 28 mm). Proportional odds regression revealed increased odds of post-operative VPI in the ECE group (OR 1.46, 95% CI 0.75-2.85) relative to the CC group. This relationship was stronger among those with bilateral cleft lip and palate (OR 3.29, 95% CI 0.86-13.52). For patients with history of prior VPI surgery, the odds of post-operative VPI in the ECE group was more than 3 times that in the CC group (OR 3.06, 95% CI 1.08-9.16).ConclusionsVPI after maxillary advancement is more likely among individuals who received early cleft care elsewhere compared to those who underwent all cleft operations at a single center.