Kathy Davis couldn't bear to look at the droopy left side of her face after surgery to remove a tumor left her with damaged nerves.
What she missed most was her smile.
"Every time I looked in the mirror I was stunned," said the 61-year-old regulator for the Environmental Protection Agency.
Then one night while browsing through an Internet chatroom, she read about a doctor from Johns Hopkins who was using a twist on a standard surgery to fix the smiles of people like herself who suffer from facial paralysis.
Dr. Kofi Boahene, an associate professor of otolaryngology, dermatology and head and neck surgery at the Johns Hopkins University School of Medicine, was able to perform that surgery on Davis nearly three years ago and now she can smile again. The results are better than she ever expected.
Boahene and a team of surgeons have improved the smiles of a dozen patients using his new technique. A paper on the outcomes of the surgeries was published in JAMA Facial Plastic Surgery in March.
The standard surgery for facial paralysis involves doctors' transplanting muscle harvested from the patient's thigh onto one area of the face, connecting nerves to enable movement. The muscle works to pull up one part of the paralyzed side of the mouth. That surgery was limited and could only produce a smirk or a small, closed-mouth smile like the one on the Mona Lisa, the famed painting by Leonardo da Vinci.
"The droopy face becomes more symmetric," Boahene said. "You get some movement, but you can't really see the teeth."
He wanted his patients to have big, expressive toothy smiles. Ones that made their eyes crinkle with joy.
Boahene modified the surgery so that the thigh muscles are placed in different locations, pulling the face at different angles. So he might transplant the muscle at the corner of the mouth or extend it from the upper lip to the cheek. The result is a wider, more vibrant smile that shows gum and teeth on both sides of the face.
The modified surgery performed at Hopkins is the next evolution of muscle transplantation for those with facial paralysis, said Dr. Kalpesh T. Vakharia, assistant professor of facial plastic and reconstructive surgery at the University of Maryland School of Medicine.
Other doctors around the country are working on similar procedures, he said.
"They took it to the next level by modifying the process," said Vakharia, who performed earlier versions of the surgery as a resident. "I expect to see more of this type of surgery."
Creating a more natural-looking face is a key factor to improving the quality of life for people who have facial paralysis from tumors, strokes, birth defects and Bell's palsy, a disorder where damage or trauma to the nerves in the face cause paralysis. Like Davis, they may struggle to cope with a disfigured face. It can lead to self-esteem issues and cause people to avoid going out in public.
Patients who get surgeries to improve their smiles often get other procedures to improve their appearance as well, such as surgeries to raise their eyebrows or Botox injections and fillers to improve symmetry of the face, Vakharia said.
"It is a huge issue," Vakharia said. "A lot of the patients are made fun of and they are ridiculed. Societal perception of them changes when they're not able to move their face."
The Hopkins surgeons performed the modified surgery on 10 women and two men between June 2015 and December 2016. All of the patients were able to smile by four months after the surgery. The patients, who ranged in age from 20 to 64, showed on average an extra three teeth and more of their gums when they smiled. The patients' faces were also more symmetrical and the eyes of four patients crinkled when they smiled.
During surgery, the doctors positioned the new muscles so that they pulled the lips up in a half-smile to match the side of the face that was not paralyzed. They connected the nerves and blood vessels from the newly transplanted muscles to the side of the face that was not paralyzed.
So when the brain sends a signal to smile, activating the muscles on the side of the face that is not paralyzed to lift, that message is sent to the paralyzed side of the face, too.
Boahene said he focuses on improving people's smiles because it expresses positive emotions. His patients who can't smile may be perceived as angry, sad or disgruntled, he said. It can affect the way people approach and react to them. A paralyzed mouth also can cause other problems, such as drooling and food falling out of their mouths when they eat. And they may have problems speaking and blinking.
Their demeanor changes dramatically after surgery, Boahene said.
"They dress differently," he said. "They pull their hair back where before they wore hairstyles that covered the side of the face. Now they don't cover their mouth anymore. And they can laugh, eat in public and socialize again."
There are some risks to the surgery, though none of the 12 patients treated at Hopkins have experienced them. Some patients may swell or have fluid retention where muscle was removed from the thigh. Others may need small adjustments to the transplanted muscle in the face to perfect the smile.
Boahene said it is best to come as early as possible after paralysis, when it is easier to connect nerves. Some patients may come after they have exhausted all other options, yet the surgery could remain an alternative, if more difficult.
Davis was relieved after talking to Boahene about the surgery and anxious to get it done. She tried not to set her expectations too high in fear that the procedure might not work.
Three months and four days after the surgery, which was covered by her insurance and cost around $30,000, Davis was sitting in her office when she felt a twitch in her face. She started to cry and ran downstairs to see her husband, who works in the same building. He too could see the twitch.
Davis is now able to smile, eat in public and her diction is clearer.
"Now when I look in the mirror," she said, "I don't want to turn and run away."