Current problems after three revisions 9 years ago include large dent in the left sidewall, hollow gap between the left rim graft and the tip, round left rim graft showing under skin, asymmetric and pointy tip, and saddle deformity and thin over resected septum. The left sidewall seems like all think skin. May need rib to make spreader grafts and septum extension and alar rim graft. How is it decided if shield graft is needed for the tip? Is a shield graft effective?