The primary goal of palatoplasty is to allow normal speech through the correction of velopharyngeal incompetence. Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to postoperative fistula formation. Fistulas may in turn contribute to velopharyngeal incompetence. Reported fistula rates vary widely, ranging from 0% to greater than 70%; recurrence rates after attempted repair approach 65% in some series. These lesions therefore represent a significant clinical burden. Acellular dermal matrix materials have been introduced into various phases of palatoplasty as a strategy to augment repairs and minimize postoperative fistula formation, as well as repair fistulas when they do occur. In this article, the authors review the existing literature regarding acellular dermal matrix in palatoplasty and describe their own algorithm and results for primary and secondary palatoplasty in which acellular dermal matrix plays a central role.