Cephalic Alar Base Malposition: Recognition and Correction with an Advancement Flap.

BACKGROUND: Cephalic alar base malposition (CABM) represents an underrecognized cause of nasal base disharmony and is frequently misdiagnosed as alar rim retraction. In this condition, the alar base is vertically displaced in a cephalic direction, creating imbalance in the alar-columellar relationship and often exaggerating the appearance of nasal tip ptosis. This study describes a reproducible surgical technique using a full-thickness advancement flap to reposition the alar base inferiorly while preserving the natural contour of the alar-facial groove. METHODS: A retrospective study was performed including patients who underwent primary or revision rhinoplasty between January 2023 and January 2025. Patients diagnosed with CABM were treated using a standardized surgical protocol based on full-thickness alar base release and inferior advancement of both cutaneous and vestibular components. Preoperative and postoperative outcomes were assessed through standardized photography and patient-reported satisfaction using the Utrecht Questionnaire. RESULTS: During the study period, 101 patients were diagnosed with CABM and underwent correction using the described technique. Follow-up ranged from 12 to 24 months. Patients who completed postoperative Utrecht assessments demonstrated significant improvement in satisfaction scores (P < 0.0001). Complication rates were low and included increased nasal hair visibility (5%), minor unfavorable scarring (4%), and revision for asymmetry in two cases. CONCLUSIONS: The advancement flap technique effectively corrects cephalic alar base malposition by restoring the vertical height of the alar insertion rather than relying on excisional methods. Nasal base harmony depends not only on width but also on the vertical position of the alar insertion. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .