Discussion about masseter muscle and jaw implants

Hi, 

Implants aren't discussed here a lot which is understandable, though based on what I've been learning about, I thought they might prompt an interesting discussion.

I'm due to get double jaw surgery soon to correct bimax recession, and while this will correct most all problems, it doesn't do anything about ramus height. To address this aspect, I will also be getting custom lengthening jaw angle implants at the same time. These will be modelled on the same CT scan used to plan the BSSO, Le fort 1, and counter-clockwise rotation. 

While other types of implants seem to have a more straightforward effect, jaw angle implants seem to be a little more complex due to the area; some people get a really great result that looks very aesthetic, whereas others just seem to get this puffy, bulky effect, and it's not completely clear why. Standard implants add purposeful width to the face where the one's I'm wanting to get will add a little width but mostly tackle ramus length, so it's worth noting that most of these poorer outcomes are with implants that focus mostly on adding width, hence the bulk issue.

I have a couple of ideas as to why this is the case:

Post-operative swelling: While certainly not the be-all-end-all of this issue, I think this is partly what we're seeing in some of the before and afters. While most swelling reduces after a few weeks, residual swelling can last up to about six months, making for a puffier overall appearance until it resolves.

Implant design: This is pretty much down to the surgeon's skill, but if the implant isn't designed correctly and bespoke to the person's individual needs, it's understandable a less desirable aesthetic outcome may occur. Perhaps the overall length of their face wasn't taken into account, for example.

Masseter muscle: I think this is perhaps the most important issue, and is what I'm most interested to hear your input on. We've all seen that image of masseter muscle hypertrophy patterns (attached below), and it would make sense to me that adding a jaw implant that widens the jaw to each of the face types in this image would produce different results. 

I'm not sure where this image originates from or if it's from a study (if anyone knows, please link it), but adding a widening jaw implant to the middle image would surely just accentuate that masseter muscle pattern, making the jaw wider but not necessarily better looking.

Someone with the face and masseter muscles on the right may expect to experience something similar to the face on the left if they had jaw implants, albeit not as pronounced, perhaps. 

People here are far more knowledgeable than me on the topic of facial growth and muscle insertions, so do you think my theory makes sense?

Taking it further, I wonder what the effect of having a vertical lengthening implant on the middle face would produce, and the effect it would have on this higher masseter muscle insertion point; perhaps it would actually balance the face out by stretching the masseter muscle into a more elongated position. After all, it is invariably people who have good jaws with a long ramus in the first place that have the masseter muscle patterns of those on the right and left. 

It also potentially brings into question the benefits of masseter hypertrophy by chewing. If you have the face in the middle, I guess chewing mastic gum regularly wouldn't be the best idea. 

Interested to hear your thoughts, 

Many thanks!