Asymmetric velopharyngeal incompetence (VPI) has a diverse etiology, but those without any underlying cleft, hemifacial microsomia (HFM), or facial asymmetry are rarely encountered. Such cases have been reported within the last few years, with unilateral velopharyngeal hypoplasia identified to be the underlying abnormality in these patients. However, there have been no reports to date on asymmetric VPI from idiopathic hemipalatal hypoplasia. A retrospective review of patients whose conditions were diagnosed with asymmetric VPI owing to hemipalatal hypoplasia and who do not have underlying cleft, HFM, or any significant facial asymmetry was performed. During a 10-year period, 5 patients with asymmetric VPI from idiopathic hemipalatal hypoplasia were treated at our center. Four of 5 of these patients presented with nasal regurgitation. Two were found to have tonsillar enlargement on the side of the hemipalatal hypoplasia, and another had an ipsilateral tongue mass that subsequently required wedge excision. Two were managed conservatively with speech therapy, whereas the other 3 developed speech problems that required surgery. The first patient underwent a skewed pharyngeal flap, but her speech problem improved only after a second surgery, which involved a centralized pharyngeal flap. The speech problems of the last 2 patients were corrected with a centralized pharyngeal flap. Hence, we conclude that patients with asymmetric VPI from idiopathic hemipalatal hypoplasia, compared with those of other etiology, particularly unilateral velopharyngeal hypoplasia, seem to present in a different manner. When surgical intervention is indicated for correction of the speech problem that eventually develops, centralized rather than skewed pharyngeal flap seems to be more reliable.