One of the most common techniques in open structure rhinoplasty, either primary, revisional or ethnic, is some kind of dorsum grafting to define, position, augment, shape and model the nasal dorsum. Dorsum grafting is one of the most creative, artistic and challenging rhinoplasty techniques, demanding the best skills, judgment and planning from the surgeon.
The main goal is achieving the desired effect with the dorsum graft but preventing its presence is detectable or adds any kind of deformity; being naturalness and undetectability absolutely feasible goals, however and eventually the graft placed at the dorsum might be explicit, detectable and its contour, ridges, shape and prominence be obvious to the observer's eye; needless to say this is absolutely unsightly and needs surgical revision.
To prevent the tombstone nasal dorsum deformity the surgeon has to shape, tailor, carve and model the graft in a highly customized to patient's nose anatomy fashion, considering critical factors like the thickness and transparency of the skin, the amount of subcutaneous tissue, the firmness and shape of the cartilage employed for the graft, the projecting vector towards the skin, etc.
Very specific maneuvers aiming to prevent graft visibility are crushing it, scoring it, bevel its edges, adjust its thickness, warping it or adding on its top and beneath the skin camouflage layers like perichondrium or temporalis fascia grafting.
Patients warning: only highly experienced surgeons who have underwent optimal training and have performed already a large number of closed approach and non structure rhinoplasties should execute nose grafting and structure rhinoplasty cases, should they feel capable and comfortable with the challenge.