May 16, 2011 -- Caitlin Cowen, 19, of Thibodeaux, La., laughed as she talked about majoring in mass communications. Her laugh signaled so much about her enthusiasm, especially since two years ago, Cowen couldn't even smile.
"A smile was a simple form of communication," said Cowen, a sophomore at Louisiana's Nicholls State University. "I felt like if I was happy, I couldn't show it. So it meant that I wasn't really happy."
In 2008, Cowen suffered partial paralysis after undergoing surgery to remove a tumor from the right side of her brain stem. Cowen was bound to a wheelchair for months as she worked to regain strength and overcome paralysis on the left side of her body, paralysis that made it impossible for Cowen to move the muscles that would allow her to smile.
In two procedures, surgeons took nerve and muscle tissue from Cowen's thigh and implanted it into the paralyzed side of her face.
While surgeons have used free gracilis transfer for more than a decade, it was considered arduous and could take up to 12 hours, according to Dr. Mack Cheney, a professor of facial reconstructive surgery at Harvard Medical School, and one of Cowen's doctors.
But free gracilis transfer has advanced so dramatically in the past five years that it should be considered first-line therapy for children who have facial paralysis, according to a paper released Monday in the Archives of Facial Plastic Surgery, which Cheney co-wrote.
"The outcomes have been better," said Cheney. "The procedure has become more precise."
Free gracilis transfer works for patients who are born with facial paralysis, as well as for those who have endured brain tumors or other traumas that have caused paralysis, said Cheney, who oversees about four of these procedures each month.
Cheney said that facial paralysis is emotionally hardest for patients like Cowen, who once had normal facial function.
"The ability to communicate and understand emotional signals go away, which is different from patients who never had that facial function to begin with," he said. "When you lose it, you feel the difference."
Throughout her senior year of high school and freshman year of college, Cowen struggled to regain normal facial expressions.
"Talking with my friends, I didn't feel like I could laugh at what they're saying. I felt like if I couldn't laugh at them, I was being mean," she said.
Although she had to give up her spot on her high school dance team, Cowen said the hardest part of her paralysis was not living in a wheelchair but the inability to smile.
"That is really what made me feel the most awful," she said.
But a few months after Cowen's second surgery, nearly two years after the brain stem surgery that left her partially paralyzed, Cowen could smile again.
"I started seeing teeth and more teeth," she said. "We had a party for our sorority, and when I saw the picture, I saw I was really smiling."
Cowen's family was so moved by the results they wrote a letter to her doctors at the Massachusetts Eye and Ear Infirmary, including Cheney.
"When you can't smile it's like a form of communication has been taken away," they wrote. "We spent many a late evening comforting her as she struggled with the psychological aspects of her facial paralysis."
"It's interesting to see what the restoration of a smile can do psychologically," said Cheney. "I'm always amazed as to how much more integrated into their lives they are."
In March, Cowen was crowned queen of her sorority's mardi gras dance. And in each of her photos, she was all smiles.
"Every time I see myself smile, I think it's awesome," said Cowen. "I think I appreciate it more."