Tuesday, June 12, 2018

The smile and what the smile means

Kevin Portillo uses a computer to exercise his facial muscles while therapist Ann-Ashley Field looks on.

     I'm waiting for someone to ask me why I write for Mosaic Science—complex medical stories that take about a year to create, between crafting proposals, having a few rejected, finally getting one approved, then doing the work. I was actively researching and writing this latest piece, which went up over the weekend, for at least five months.
     But no one has, so I'll answer it anyway. The topics are fascinating. The first, "Face Fear," was about why we are afraid of those with facial differences, and what it's like to be disfigured—a topic I pitched for years before Mosaic said, "sure." The second, "Pray for Kumamoto & Kumamon," was on cuteness as an academic field—Mosaic sent me to Japan for a week. The third, "How to fall to your death and live to tell the tale," was about falling as a medical crisis, and this, my first assignment from Mosaic, on smiling, is intended to run in conjunction with the Wellcome Collection exhibition, Teeth, now running at their museum in London. 
     I like doing them—and this might sound a little crazy—BECAUSE they're so much work. As a writer ages, the tendency is to phone it in, particularly when you can turn your palm to the sky and pontificate endlessly on the news of the day. That's what readers seem to want most. So I figure, if I'm writing these pieces for Mosaic, I must be still on my game.
    This piece was the opposite of phoning it in. The assignment was "Write 5,000 words on smiling." That's it. I know Mosaic wants their stories built around specific individuals, and it took a couple months just to find Kevin Portillo. Thanks to him, his family and everybody at the Children's Hospital of Philadelphia. A first rate operation.
     Enough throat-clearing. Mosaic publishes under a creative commons license, meaning that you are free to republish their articles however you see fit. The Guardian newspaper has already run its version in their Observer magazine. Here is the Mosaic link, using their photographs. I took photos too, and here I'm using my own. It's very long, so take your time.

     Kevin Portillo practices smiling every day at home. Usually after brushing his teeth. Or when stopping by the bathroom, or anywhere with a mirror.
     He hooks an index finger into each side of his mouth and pulls gently upward. He puckers his face into a kiss, then opens wide into an O, trying to limber up his facial muscles. He practices both the Mona Lisa – slight, closed lip – and a wide, toothy smile.
     At least he’s supposed to do his exercises every day. Being 13, the American 7th grader sometimes forgets, though he understands their importance.
     “I need to stretch my cheeks,” he says. “I do it for a couple minutes. I have to do it every single day.” He exercises so much that his jaw sometimes hurts.
     Kevin was born in New Jersey with a rare malignant vascular tumour, a kaposiform hemangioendothelioma, covering the left side of his face, squeezing shut his left eye and pushing his nose to the right. Immediately after his birth, doctors whisked him away to another hospital in another state – the Children's Hospital of Philadelphia. His mother didn’t see him again until he was eight days old.
     The doctor told Kevin’s parents that the chance of him surviving was slim.
     But survive he did. However, the large tumour and the damage from its treatment prevented him from being able to do one of the most fundamental things humans do.

     Most babies are born immediately able to communicate with the world around them in one way: by crying.
     A smile is the second signal babies send out. Newborns can smile spontaneously, as a reflex. This is sometimes misinterpreted by new parents as a reaction to their presence, a reward for their intense concern and sleepless efforts. However, it’s not until to six or eight weeks of age that babies smile in a social way. Blind babies do this at the same time.
     That new parents’ sometimes optimistically interpret the first reflex smiles as meaning something more underscores the duality of smiling: there is the physical act and then the interpretation society gives to it. The smile and what the smile means.
     A smile is clear enough on a physical level. There are 17 pairs of muscles controlling expression in the human face, plus a singular muscle, the orbicularis oris, a ring that goes entirely around the mouth.
     When the brain either reacts to a stimulus spontaneously or decides to form an expression intentionally, a message is sent out over the 6th and 7th cranial nerves. These branch across each side of the face from the eyebrows to the chin, to some combination of muscles controlling the lips, nose, eyes and forehead.
     The basic upward curving smile is achieved primarily by two pair of zygomaticus muscles, major and minor. These connect the corners of the mouth to the temples, tugging lips upward, often accompanied, depending on the underlying emotions and thoughts, by the levator labii superioris, raising the upper lip, and other muscles of the face.
     And as for the oft-cited folk wisdom about how it takes more muscles to frown than smile – the jury’s still out, especially as different smiles require different numbers of muscles. However, one source suggests the number could be very similar (and that one particularly insincere smile might take not much more than the pair of risorius muscles).  
Kouros (Getty Villa, Los Angeles)

    It is when we leave the realm of physiognomy, however, that the smile becomes enigmatic. This contraction of various facial muscles resonates across the entire arc of human history, from grinning Greek kouros sculptures from 2,500 years ago, right up to Internet emoji, those little images that pepper our communications.
     One study of smartphone users from 60 countries showed that emoji with smiling faces are by far the most prevalent in messages. The most popular overall – the face with tears of joy – was picked as the 2015 Word of the Year by Oxford Dictionaries.
     Just as this emoji expresses more than mere happiness – tears adding the ironic twist so popular online – interpreting the nuance of smiles, which can convey so much more than “happy”, is a challenge whether dealing with art history or interpersonal encounters or the cutting edge of artificial intelligence.
     Smiles aren’t as simple as they might seem. What a smile means depends on who is seeing it, when it is flashed, where and by whom.

     A comprehensive 2016 study, published in the Journal of Nonverbal Behavior questioned thousands of people in 44 cultures about sets of photographs of the same eight faces. The first group saw a set of photos with four people smiling and four not. The second group saw photos where the people smiling in the first set were presented as non-smiling, and vice versa.
     People from certain countries – Germany, Switzerland, China – deemed the smiling faces more intelligent. Others – Japan, India, Iran – favoured non-smiling faces.
     Why? That question is also complicated, but in essence, the study’s researchers concluded it has to do with trust, with whether a society is set up so that its members assume that other people are dealing with them honestly. “Greater corruption levels decreased trust granted toward smiling individuals” the authors concluded.
     Which might explain why Russians smile less frequently than Brits. If you’re expecting to be deceived, then a stranger’s smile is seen as part of that deception, and therefore malign.
     That attitude harkens back to a very old view of smiling as being opposed to pious solemnity. Despite all those smirking sculptures, there is exactly one smile in the Old Testament – Job, ironically – though in many passages faces are said to “shine”, which could mean smiling or could mean heavenly radiance.
     Eastern religions often use the smile to denote enlightenment. The actual name of the religious text Flower Sermon, which describes the origin of Zen Buddhism, is “Pick up flower, subtle smile”. The Buddha and various religious figures were depicted with serene smiles, though the original Buddhist texts are as devoid of smiling as Western scripture. Jesus weeps but never smiles.


     Nor did Kevin Portillo, not fully. He did not smile when expected. At 5 weeks old he was already a week into chemotherapy with vincristine, an anti-cancer drug so powerful it can cause bone pain and skin rashes. Doctors warned his mother that the treatment might leave him blind, or deaf, or unable to walk.           
Kevin Portillo as a newborn
     “If he survived,” says his mother, Silvia Portillo, in Spanish. “The doctor always said he cannot give us hopes that he may survive.”
     Whether stunted due to the tumour or killed by the chemo, Kevin’s 7th cranial nerve withered. That nerve originates at the brain stem then branches out across the face. It is susceptible not only to tumours, as in Kevin's case, but to rare conditions such as Moebius syndrome, a congenital facial paralysis due to missing or stunted cranial nerves. You can’t smile, frown, or move your eyes from side to side.
     “You essentially have a mask on your face,” says Roland Bienvenu, 67, a Texan with Moebius syndrome.
     Without being able to smile, others “can get the incorrect impression of you,” says Bienvenu. “You can almost read their thoughts. They wonder, ‘Is something wrong with him? Has he had an accident?’ They question your intellectual ability, think maybe he's got some intellectual disability since he's got this blank look on his face.”
     A lopsided smile can be as problematic as no smile at all.
     “I have half a smile, so even with that I am able to successfully convey emotion,” writes Dawn Shaw, born with a teratoma – a fast-growing tumour that was interfering with her wind pipe. “The hardest part for me was seeing photos of myself smiling, because smiling exaggerates the fact that half my face doesn’t move very much. But eventually I learned to own it. That is me. That is how I look.”
     The challenges stemming from lack of a smile are frequently compounded. When people have a medical condition severe enough to keep them from smiling, other difficulties tend to be involved.
     “He was different than the other kids,” says Silvia Portillo of her son. “He was fed for four years through the G-tube in his stomach. He wasn’t able to have a normal life, because every few hours he had to be connected to the machine to be fed.” Little kids, being curious, would look and ask what happened to him, she says.


     While those who cannot smile can blame the state of their facial nerves and muscles, those who can smile are often concerned with a different aspect of physiognomy: their teeth. More than $3 billion (US) are spent worldwide on teeth-whitening products, with billions more spent on braces, and on purely cosmetic dentistry: straightening crooked teeth, for instance, or reducing the amount of gum that shows when a person smiles.
     Caring for the state of your teeth is not a modern concern. The Romans had dentists and used chewing sticks and toothpaste. They preferred dazzling white smiles, sometimes rinsing their teeth in urine to enhance the effect.
     Despite some modern perceptions, the ancients had surprisingly good teeth, for reasons that have nothing to do with dentistry. A CAT scan of 30 bodies of adults recovered at Pompeii found they had “perfect teeth”. This was due to two factors: short life spans – they didn’t live long enough for their teeth to go bad – and, most importantly, lack of access to refined sugar, that great destroyer of dental health.
     When piety was an overarching value, smiles were, well, frowned upon, as the precursor of laughter, which was held in true disdain. Prior to the French Revolution, broad smiles in art were overwhelmingly the realm of the lewd, the drunk and the boisterous lower classes.
     “The whole face ought to reflect an air of seriousness and wisdom,” John Baptist de La Salle wrote in his 1703 The Rules of Christian Decorum and Civility, allowing a person might, under certain circumstances, convey the impression that he is happy, provided it is done within limits. “There are some people who raise their upper lip so high or let the lower lip sag so much that their teeth are almost entirely visible. This is entirely contrary to decorum, which forbids you to allow your teeth to be uncovered, for nature gave us lips to conceal them…”
     In The Smile Revolution in Eighteenth Century Paris, Colin Jones argues that smiling reflected the gathering sense of individual worth that went along with the beheading of kings:      

This shift in social practises and in sensibilities involved the emergence of the perception, common in our own day, that the smile offered a key to individual identity. In late eighteenth-century Paris, the smile came to be viewed as symbol of an individual's innermost and most authentic self. In a way that was perceived as both novel and modern, it was held to reveal the character of the person within. 
     Photography, by capturing smiles, eventually helped popularize them. Though the sitters in 19th-century photographs still rarely smiled, a neutral continence being both easier to hold over the long exposure necessary at the time and less likely to detract from the gravity of the occasion.
     “A photograph is a most important document, and there is nothing more damning to go down to posterity than a silly, foolish smile caught and fixed forever,” humorist Mark Twain was quoted as remarking in the 1913 memoir of an acquaintance.
     Around the same time, however, Kodak in the US launched extensive advertising campaigns to help consumers see photography as a means of recording joyous events and celebrations.

        Over the the century, smiles showed a confidence in keeping with the rise of modern capitalism. “An insincere grin? That doesn’t fool anybody,” Dale Carnegie wrote in his 1936 bestseller, How to Win Friends and Influence People, embraced as a life guide by millions. “We know it is mechanical and we resent it. I am talking about a real smile, a heartwarming smile, a smile that comes from within, the kind of smile that will bring a good price in the marketplace.”
     Part of the attractiveness of smiles is they are so easily extended. Part of their menace is that they can also be just as easily withheld.
     “For a salesman, there’s no rock bottom to the life,” Charlie says at the end of Arthur Miller's "Death of a Salesman.” “He don’t put a bolt to a nut, he don’t tell you the law or give you medicine. He’s a man way out there in the blue, riding on a smile and a shoeshine. And when they start not smiling back – that’s an earthquake.”


     Once Kevin was able to eat food, go to school and enjoy usual childhood pastimes – he became passionate about soccer and playing the drums – he still felt the tremors of a half smile in a world solidly established upon “a cultural expectation of pearly perfection,” as Richard Barnett writes in his book The Smile Stealers.
     “I couldn’t smile on my left, I only smiled on my right,” says Kevin. “My smile was weird...people kept asking what happened to me, why I'm like this. I keep telling them I was like this when I was born.”
     If you see someone in a wheelchair, you anticipate that the person might have trouble walking and assume a physical condition is involved. But facial paralysis carries no telltale equipment, and is rare enough that the unaffected population is not generally familiar with congenital conditions or those that come later, such as Bell’s Palsy, an inflammation of the sheathing around the facial nerves on one side that paralyzes half the face, causing the eye and corner of the mouth to droop.
     Usually temporary, Bell’s Palsy generally slowly goes away as mysteriously as it arrives. Doctors suspect it is caused by a viral infection., and usually strikes 
men and women between the ages of 15 and 60. . There are also traumatic events – car wrecks, sporting accidents – that damage nerves and muscles in the face, plus congenital irregularities such as cleft palate. 
     A common condition that can also affect the smile is stroke. A sagging smile or face dropped on one side is one of three signs that a person has had a stroke and needs immediate emergency care.
     ‘Face’ is the first symptom in the ‘FAST’ mnemonic for the symptoms of stroke – the A refers to weakness or numbness in one of the arms; S is for speech, which may be slurred or garbled; the T is for ‘time’ to call the emergency services. Often, there is permanent damage.
     While losing a smile is huge at any age, it can have a particular impact on younger people, who are starting out, forming the bonds that will carry them through the rest of their lives.
     Or trying to.
     “It’s a huge problem,” says Tami Konieczny, supervisor of occupational therapy at the Children's Hospital of Philadelphia (CHoP). “When you look at somebody, the first thing you see is their face, their ability to smile or not smile, or an asymmetrical smile. It’s your social world.
      “If someone can’t read your facial expressions, then it’s difficult to be socially accepted. It’s hugely devastating for kids. I had kids photoshopping their pictures. They are taking mirror images of their good side and copying it, photoshopping their own pictures before posting them to social media.”


     Photoshopping might work on Facebook. But fixing a smile bisected by nerve damage and subsequent muscle loss – because Kevin couldn’t move the muscles on the left side of his face, they atrophied – is far more complicated. Sometimes, it requires multi-stage plastic surgery spread out over a year or more.
     There are two major procedures available for facial reanimation, according to Dr Phuong Nguyen , a plastic and reconstructive surgeon at CHoP, tells me.
     The newest, which has its roots in older techniques, is called a lengthening temporalis myoplasty – taking part of the broad band of muscle that powers the jaws and re-purposing it to draw up the lips.
     That wasn’t ideal for Kevin because he had one side of his face working, so the older, more complicated surgery was used to take advantage of that.
     “Kevin had the most commonly done one, a classic two-stage cross face nerve graft followed by a free gracilis muscle transfer,” says Dr Nguyen. “To be perfectly honest, when Kevin had his stage, we weren’t familiar with the lengthening temporalis myoplasty procedure yet.”  
Dr. Phuong Nguyen, Children's Hospital of Philadelphia

     He learned the procedure from facial reanimation pioneer, Dr Ronald Zuker, a Canadian plastic and reconstructive surgeon, and from its originator, French surgeon Dr. Daniel LabbĂ©.
      “My preference is to do it when kids are five years of age,” says Dr Zuker. “At the time, if I can restore a smile for them, they can go to primary school, meet kids on the playground, meet kids in class. They have their smiles, and are well-equipped to handle that situation.”[21]
     Why put children through what is still elective surgery?
     “It’s incredibly important to be able to interact with humans on a face-to-face basis,” says Dr Zuker. “If you don't have the ability to smile, you are at a disadvantage. People cannot understand your inner emotions. They mistake your appearance for being [uninterested], or not too bright, or not very involved in the conversation.”
     Still, some parents prefer to wait until their children are older and can participate in the decision.
     “If families want to wait, that's perfectly fine,” says Dr Zuker. “Sometimes when a kid is 9 or 10 they look in the mirror and say, ‘You know, I really want this surgery.’ That's the time to do it.”
     Which is what happened with Kevin Portillo. He was doing well, “even with that scar on his face, has always been popular at school,” says his mother. “He’s always been a happy kid.”
     But there were kids that made fun of him, she says. “When he was about 9, he used to say, one day he was sad. I said ‘What happened to you?’ He said, ‘Some kids, they’re not my friends. They laugh at me because I look funny.’ It was really hard for us as parents.”
     “We always wanted the surgery,” his mother says. "But we were told it was impossible. We had to wait to see how everything was changing.”
     At age 10, Kevin told his parents that he wanted to do what most people do without giving it a second thought. He knew it would be a long, painful difficult procedure, but it was one he wanted to undergo.
     “He’s very engaging, very motivated,” says Anne-Ashley Field, his occupational therapist at CHoP. “His goal, I wrote in my notes, was to have a symmetrical smile.”


     As with smiles themselves, so the scientific study of smiles reflects the cleavage between the physical and the interpretive. The former is part of the long history of plastic surgery, which tends to center around the nose, both as the center of the face, and the victim of diseases like syphilis and the knives of vengeful authorities and warlords.
     The father of modern plastic surgery, Harold Gillies, wrote in 1934 reporting that restoring the ability to smile made the patients “feel much more comfortable.” In addition, Gillies observed, “the psychological effect is also one of considerable value.”
     Charles Darwin’s discusses the interpretation and value of smiles in the landmark The Expressions of the Emotions in Man and Animals, his follow-up to 1871's Descent of Man. (And a book, it should be noted, greatly influenced by surgeon and anatomist Sir Charles Bell, for whom Bell’s Palsy is named. Bell did pioneering work on the idea that the brain communicates its commands through nerves.)
     Like many, Darwin sees a smile as the first part of a continuum.
     “A smile, therefore, may be said to be the first stage in the development of a laugh,” Darwin writes, then reverses course, musing that perhaps the smile is instead the remnant of laughter. He observes his own infants closely, detecting in two their first smiles at six weeks, and earlier in the third. He comments how smiles do more than merely convey happiness, mentioning the “derisive or sardonic smile,” the “unnatural or false smile” and showing photos of such smiles to see if his associates can read what they mean. 

      The scientific study of smiles finds differences in gender (generally, women smile more) and culture. Smiles are definitely communicative – people smile more when in public than they do when alone, or when interacting with others in public than when not.
     Scientists have shown that smiling faces are far easier to recognize than other expressions. What they don’t know is why.
     “We can do really well recognizing smiles,” said Dr. Aleix Martinez, a professor of electrical and computer engineering at Ohio State University and founder of its Computational Biology and Cognitive Science Lab. “This is true both for humans and for machines.
     “Why is that true? Nobody can answer that right now. We don’t know. We really do not know. We have a classical experiment, where we showed images of facial expressions to people, but we showed them very rapidly: the image of facial expression at a fraction of a second: 10 milliseconds, 20 milliseconds. People can detect a smile even in exposures smaller than 10 milliseconds. I can show you an image for just 10 milliseconds you can tell me it's a smile. It does not work with any other expression.”
     Fear, he says, takes an exposure time of 500 milliseconds – 50 times as long as a smile, which makes absolutely no sense, evolutionarily speaking. “Recognizing fear is fundamental to survival,” he says, “while a smile.... But that’s how we are wired.”
     Individuals can be recognized more easily if they’re smiling. Alibaba, China’s answer to Amazon, launched its new facial recognition payment system called “Smile to Pay” in September 2017.
     Despite science’s early start about 150 years ago, scientists are still in the stage of trying to count and categorizes types of smile among the millions of possible facial expressions.
     “One of fundamental questions in the scientific literature right now is how many facial expressions do we actually produce?” says Martinez. “Nobody knows.”
     Scientists such as Martinez theorize that smiles – as well as frowns, and other facial expressions – are remnants of humanity’s distant pre-linguistic heritage. Human language started developing as far back as 100,000 years ago, but our expressions reach back further still, to our earliest foundations as human beings.
     “Before we could communicate verbally, we had to communicate with our faces,” Martinez says. “Which brings us to a very interesting, very fundamental question in science: where does language come from? Language is not fossilized, not found in any other living species. How could something that complex have evolved from nothingness?”
     One of the hypotheses is that it evolved through facial expression of emotion, he says. “First we learned to move our facial muscles – ‘I’m happy. I feel positive with you! I’m angry. I feel disgust.’ Then language came through a grammaticalisation of facial expressions, which over time evolved into what we call grammar and language.”
     Between the confidence of the modern individual and the prevalence of computer systems, smiles could become an even greater part of our culture.



     In October, 2015, Dr Nguyen, who plays in a band, cranked up some rock music in the operating room at Children’s Hospital of Philadelphia while he began by removing a section of sural nerve from Kevin’s right ankle and attaching it to the working right side of his face, running it underneath his upper lip, to the paralyzed left.
     “We bring it across, parking it, waiting for nerves to regrow from the right side to the left,” Dr Nguyen says.
     That process took almost a year. The neurons to form along the nerve fibre advanced about a millimeter a day (about 24,000 times slower than a snail).
     Not all of those axons make it across. This means that the nerve can lose the ability to transmit information – up to 80 percent lost, and in a few cases the nerve doesn’t transmit information at all.
     “The thing with nerve-based surgery, you don’t get a lot of instant gratification or feedback,” says Dr Nguyen. “You do the procedure and don’t know if it works or not. You have to wait.”
      During that time, doctors would periodically tap areas of Kevin’s cheek, to see if the nerve was taking. “When it tingles, you know the nerve is growing,” says Dr Nguyen.
     The body has a way of covering losses. Removing that nerve did cause a small patch of skin on Kevin’s ankle to go numb. But as he was still growing, the numb patch began to shrink as the neural network took over its function.
     Once Dr Nguyen was certain the nerve was in place and functioning, it was time for the second stage of the surgery.
     One morning in August 2016, Dr Nguyen took a purple marker and wrote a “P” on Kevin’s left temple and an “NP” on his right – for “paralysed” and “not paralysed” – a common surgical precaution against the risk of cutting into the wrong side of a patient; easier than you might imagine, considering the draping done before surgery.
          “It happens,” says Dr Nguyen. “You want to make it idiot-proof.”
     He also drew a pair of parallel lines, marking the location of a prime artery, and an arrow: the vector Kevin’s smile would take.
     The surgeon made an incision from the temporal hair line, in front of the ear, pivoting back under and behind his ear, extending into his neck– the standard location for hiding plastic surgery scars. The skin on a face peels back easily. He attached three sutures to the inside corner of Kevin’s mouth and gently pulled, to gauge exactly where the muscle should be attached.
     “So you know it’s in the right place,” explained Dr Nguyen. “If you don't get this right, they’re going to have to live with it for the rest of their life.”
     The moment Dr Nguyen put strain on the triple surgical thread was the first time Kevin Portillo ever smiled on the left side of his face.
     That done, Dr Nguyen removed a 12-centimeter segment of gracilus muscle, along with a section of artery and vein, from the inside of Kevin’s left thigh, as well as the obturator nerve. The muscle was secured in place by a customized splint that hooked into Kevin’s mouth and was sewn to the side of his head to keep the relocated muscle from pulling out before it healed.
     The section was taken from Kevin’s thigh because the powerful upper leg is rich in muscles.
     “There are so many muscles that do the same function ... you don't miss this,” Dr Nguyen says.
     Well ... most wouldn’t miss it. Kevin, a diehard young soccer fan, did.
     “When the surgery came I couldn’t play,” he says. “I didn’t know it would take that long. I thought it would take a couple days and I would be back.”
     Just how long was he sidelined?
     “It was more than two weeks,” he says, sorrowfully.
     “He wasn’t concerned with how serious the surgery was,” his mother says, laughing. “He was more concerned with not being able to play soccer.”
     Over the next year, Kevin began to get motion on the left side of his mouth.
     “It’s really kind of a magical thing,” says Dr Nguyen “We do this procedure, a number of hours and effort, using not a small amount of resources. We don’t know if it works or not. I saw him post-operatively within first couple of weeks, he looked like he had this big bulgy thing in his cheek. Nothing was moving. All of a sudden, he was smiling. It was a really incredible moment.”



     Well, magic and hard work. Low tech and high tech. 
     Kevin Portillo begins his bi-weekly occupational therapy session by holding a 2-cent white plastic fork in his mouth and showing that he can maneuver it up and down. 
     “Try to purse our lips together to make it stand up,” says Anne-Ashley Field, his therapist at CHoP. “We’ve got it pretty solid in the middle. Try to work it over to the weaker side. Nice try ... and that’s harder.”
     Kevin puts on purple latex gloves and pulls at the inside of his cheek.
     “You’re going to do your stretch on the inside,” says Field. “A nice, slow hold. Good. Bring that thumb up... Do you feel like it’s getting looser than it was?”
     “Mmm-hmmm,” Kevin agrees, gloved fingers in mouth.
     She takes some photos. There is a lot of photography in facial therapy, to track progress.
     “Now give me the biggest open mouthed smile you can,” says Field. “Good. Can you make the left side go up even more? Try to make your gums even.”
     Then, after more exercises, she asks if he is ready for the computer work.
     They move into the next room, to a $20,000 Lenovo biometric therapy system. Field sticks a surface EMG – an oblong black sensor that reads electrical activity in the muscle – to Kevin’s left cheek and he plays video games, Load Ship, where he took animated boxes from a conveyor on the screen by smiling and relaxing.
     “Give me a big smile,” Field says, calibrating the device. “And relax.”
     He plays for four minutes, the game burbling a skittery kind of jazzy electronic music.
     They play a few other games: one trying to get a man to a safe spot as two serrated blue spaces come together. Then a marble maze.
     “How are you feeling?” she asks.
     “Hurts,” he replies.
     Physical rehabilitation is the part of the surgical process that often gets overlooked, but it can make the difference between success and failure.
      “It’s huge, particularly with facial palsy,” says Dr Nguyen. “You can do technically very sound surgery on two completely different patients and have two completely different outcomes based on how involved they are with their own therapy… It just doesn’t look as good .... So much of this goes into mirror therapy… training your brain… to move something that was never moving.”
     How does Kevin feel about being able to fully smile after a lifetime of not being able to?
     “I’ve been getting better on how I react. I do it automatically,” says Kevin. “Sometimes when somebody says a joke. It actually feels great now. Before it felt weird to not smile. Smiling both sides of my mouth at same time, I feel I'm one of other people who smiles right.”
     His mother remembers the moment she noticed.       

     “We were at the table, we were eating,” says Silvia Portillo. “And then we said, ‘Kevin, are you moving there?’ He started moving. Not the way he was doing today; little movements.”
     “We were eating,” he says. “I think she said something funny, and I just smiled.”
     And how does smiling affect his life?
     “Before I was actually shy,” he says. “Right now, I'm less shy, more active.”
     “I used to have trouble expressing my emotions. Now people know if I'm smiling or laughing. When I laughed, before, I laughed weird.
     “And right now, they know, bit by bit, that I was trying to smile, I was expressing my laughter and my smile. When I play soccer, and [score] a goal, I'm happy. I’m smiling, to tell everybody I scored.”


  1. I find what surgeons can do for people who are either born disfigured or get that way through accidents or burns amazing. That last photo of Kevin smiling is inspiring, both for the skill & artistry of the surgeon & that Kevin went through so many operations & all the therapy to learn how to use his new nerves.

    But a bit off topic, Trump has the creepiest smile. Most of the time, his mouth is closed & he looks like the cat that ate the canary. And when he does open his lips & show his teeth, such as when he showed himself eating a taco bowl. A $3 bill is more legit!

    1. What I found remarkable about the surgeons Neil mentioned was their humility, the absence of which is something surgeons in general are noted for. Rather than toot their own horn about their consummate skill and godlike mastery, these guys do their job as best they can and then wait 6 months to see how it comes out, giving due credit to the patients who work hard to give the surgery a fighting chance to succeed.


    2. Dr. Nguyen was extraordinary. The day I interviewed him he had flown in from Hanoi, the night before, after spending a week providing complicated plastic surgery for a nation of 40 million people that lacks a specialized cranio-facial center. A very open and engaging individual. Meeting him was the highlight of the entire experience.

  2. What a remarkable piece. Kudos to the Children’s Hospital of Philadelphia, all the physicians (bravo, Dr. Nguyen), the Portillo family and everyone else involved,
    To Mosaic for assigning this project, and of course to Neil for his time and effort in bringing it to life.
    I don’t believe I’ll ever take the “simple” act of smiling for granted again.

  3. Amazing article and also what the guy went through. Kudos to the surgeon too.

  4. I found myself somewhat able to relate to Kevin, on a scale that is smaller by many degrees. I recently had a tooth extracted and will have to wait a few months for the dental implant and crown. I find myself, for the first time ever, self-conscious about how I look when I smile-and I tend to smile a fair amount! I certainly feel more empathy now than I could have just a couple of weeks ago. I find Kevin's smile quite winning, and I hope he continues to grow more comfortable sharing it!

  5. What wonders doctors perform. The picture of the infant Kevin is frightening, barely human looking. Hard to believe he is the teen in the final shot. I know a little about what Kevin has experienced. Surgery and its' aftermath are different on the face. You feel strange for quite some time, the skin feels artificial and stiff. The needle sticks for local anesthesia are worse than any others that I have experienced, a lot of nerves involved. I avoided the tender vanities that children and women suffer from, even inventing stories to explain scars to the curious. I'm guessing that Kevin had a general for his surgery but his post op was a full glass while I had just a sip. My hats off to this brave kid.


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