The authors present a comprehensive analysis of alar retraction malformation in rhinoplasty patients. For this retrospective review they analysed 45 patients with alar-columellar disproportion. Various aetiologies were identified. Treatment of these has to be determined on an individual case-to-case basis. Specific rhinoplasty manoeuvres presented in this review include: lateral crural strut grafts, alar batten grafts, alar margin (rim) grafts, composite grafts and vertical lobule division. Cartilage grafting turned out to have a measurable effect on improving alar retraction. Composite grafts were found to be the most efficacious overall. On the basis of the results of this study, the authors identified an algorithmic approach to the management of alar retraction, which is based on the degree of measured retraction. Furthermore indications for prophylactic cartilage grafting in the form of alar strut or alar rim grafts were defined.