Asymmetric columellar show with a paracolumellar hollow - Correcting a minor defect with filler? (Photos)

Question

On base view, my columella is rotated slightly off-midline it's deviated toward my left naris rather than sitting straight. Because of that rotation, there's a soft-tissue depression on the right paracolumellar area, around the footplate region, where the tissue has lost support and caved in. So I've got asymmetric columellar show with a paracolumellar hollow on the side the columella has rotated away from. I'm wondering whether it's a flared or rotated medial crural footplate, or a caudal septal deflection driving it. Is HA filler appropriate here to camouflage that paracolumellar depression and even out the base understanding it's soft-tissue correction, not de-rotating the cartilage? And if you do think filler's reasonable, which HA would you reach for, and why that one over the others? One thing that should factor into the product choice: I had a delayed-onset granuloma to Volux once for jaw fillers so trying to avoid that cross linking tech.

Anna Chacon, MD, FAAD · Answer

You’ve described the anatomy unusually well, and I think your distinction between camouflage of a soft-tissue depression and true correction of the underlying cartilage/septal deviation is exactly the right way to approach this.

From your photos and description, this looks less like a major columellar deviation and more like a subtle asymmetry of the columellar base with relative volume deficiency along the right paracolumellar/footplate region. In that situation, HA filler can be a reasonable conservative option, provided the goal is improving symmetry in the base view rather than straightening the columella itself.

What may be causing it

The possibilities you listed are all plausible:

Slight medial crural footplate asymmetry or flare
Mild rotation of the medial crura
Caudal septal deviation creating asymmetric support
A combination of cartilage position plus thin soft-tissue coverage

The fact that you notice a hollow on the side the columella rotates away from often suggests that the problem is not simply “extra tissue” on the opposite side, but a relative lack of support or volume on the hollow side.

Is filler appropriate?

For a small, localized depression near the footplate/paracolumellar junction, I would generally consider micro-aliquot HA filler a reasonable camouflage strategy.

The advantages are:

Reversible
Allows very precise correction
Can be placed superficially enough to soften the hollow without altering nasal tip dynamics
Avoids another surgical procedure for a minor cosmetic asymmetry

What filler cannot do is:

De-rotate the columella
Correct a significant caudal septal deflection
Reposition the medial crura
Reliably improve asymmetry that is primarily structural rather than volumetric

If the asymmetry is obvious from multiple angles or associated with functional obstruction, surgery would still be the definitive treatment.

Your history of a delayed-onset granuloma to Volux is very relevant

This is the most important part of your question.

Volux (VYC-25L) uses Vycross technology, which combines low- and high-molecular-weight HA with a relatively high degree of cross-linking. Delayed inflammatory nodules and granulomatous reactions have been reported with all HA fillers, but many injectors are understandably cautious about using another Vycross product in a patient with a prior delayed-onset granuloma.

Because of that history, I would avoid Vycross-based fillers for this indication, including:

Voluma
Volbella
Vollure
Volux
What I would reach for instead

For a small paracolumellar hollow, I would favor a non-Vycross, low-to-moderate G’ HA filler with good tissue integration.

My first considerations would be:

Restylane-L
NASHA technology (not Vycross)
Excellent precision for small structural corrections
Lower water uptake than many softer fillers
Easy to place in tiny aliquots (0.01–0.03 mL)
Good reversibility profile
Restylane Defyne
XpresHAn technology
Slightly more flexible than Restylane-L
Useful if the area moves with facial expression and you want a more natural integration

For the specific area you’re describing — adjacent to the columellar base/footplate where overcorrection would be very noticeable — I would probably lean toward Restylane-L because it allows finer sculpting with less spread.

Injection technique matters more than the product

This region is vascularly sensitive, with contributions from branches of the superior labial and columellar arteries. If filler is used, I would generally think in terms of:

Very small volumes
Slow injection
Placement in the subcutaneous or supraperichondrial plane, depending on the exact contour defect
Careful assessment of blanching and vascular compromise

For a defect that appears as subtle as yours, the total volume might be 0.05–0.15 mL, not the larger amounts used in typical nasal bridge or tip augmentation.

One additional thought

Because you’ve had a delayed-onset granulomatous reaction, I would also want to know:

How long after Volux the granuloma appeared
Whether it required hyaluronidase, steroids, antibiotics, or surgical removal
Whether you have had other HA fillers since then without reaction

A single reaction to Volux does not necessarily mean you can never receive HA filler again, but it does justify a more conservative product selection and a careful risk-benefit discussion.

My honest impression

Based on your description and photos, I do think HA filler is a reasonable option for camouflaging the right paracolumellar hollow, with the understanding that it would provide soft-tissue symmetry improvement rather than true structural correction of the columellar deviation.

Given your prior Volux delayed-onset granuloma, I would avoid Vycross-based fillers and would be most inclined toward Restylane-L in very small, carefully placed aliquots, because it offers precise contour correction, minimal spread, and a different cross-linking technology from the product that previously caused a delayed inflammatory reaction.

The fact that your asymmetry appears minor and highly localized actually makes it one of the situations where a tiny amount of filler may have a disproportionately noticeable cosmetic benefit, provided the injector is experienced with nasal base anatomy and conservative micro-correction techniques.

Asymmetric columellar show with a paracolumellar hollow - Correcting a minor defect with filler? (Photos)

Answers (1)

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