From the left side, the Brazilian law student was a picture of youth and femininity. She had silky chestnut brown hair and a delicate jaw line. She wore high-fashion sunglasses, tailored clothes and strappy high heels, and joked about marrying actor Russell Crowe.
But when Rafaella Calixto Oliveira turned, she revealed the side of her face that repulsed children on the streets of Sao Paulo, her home town.
Its scars and discoloration are the signature of arteriovenous malformation, a disease in which blood vessels grow abnormally large and become tangled. Capillaries that usually connect the larger veins and arteries do not develop, nor do sphincters that control the flow of blood. The diseased vessels expand relentlessly.
As her doctor, James Suen, said, "They keep coming back."
AV malformation means pressure and bleeding and pain, but Oliveira, 23, buried her internal struggle and carried herself bravely.
"Throughout my life, I've been tested," she said. "My integrity, my intelligence, my inner strength, my hopes and my faith. But I always looked inside, searched who I was and asked God for guidance."
Early in her treatment, Suen, who has written textbooks on head and neck surgery, said, "She is a tough lady. For her to go through all the problems and still be so positive is just amazing. . . .
"Her goal is not beauty; it's to live productively."
Oliveira had displayed lesions as a 6-month-old and went through a drastic blood-blocking procedure called embolization when she was 8. The disorder grew worse when she reached adolescence.
"In 1999, my face just opened up," she said. It hemorrhaged for 12 hours straight.
The Brazilian surgeons' desperate treatments would calm the area for a few months, but as Suen said, "They only made the AV malformation angry."
Oliveira was not getting better.
"I never thought about leaving Brazil," she said, but the severe hemorrhaging troubled her. "I didn't know what would happen next. I thought, 'I guess I will die.' "
Research led her to Arkansas Children's Hospital and Milton Waner, a surgeon who had received media attention for saving babies with blood-vessel deformities similar to AV malformation.
Without waiting for approval from the Brazilian insurance company CASSI, Oliveira and her mother, Iza Calixto, headed on May 19, 2003, for Little Rock.
Oliveira was in far worse shape than Waner initially thought. Her malformation had become massive, aggravated by radiation and embolization.
Waner called in Suen from the University of Arkansas for Medical Sciences.
Explaining that he had done more than 30 major operations like the one Oliveira would undergo, Suen said: "I like to do these. They keep me inspired."
Four days after leaving Brazil, Oliveira was in surgery.
It turned out to be a 26-hour marathon. She lost four pints of blood and required cadaver tissue to fill in her pared-down face (tissue she later rejected). Still, Suen stopped the bleeding around her eye and in her nasal passages while returning some bulk and healthy tissue to her temple and jaw.
He believed the constant bleeding was now curtailed to the point that laser surgeries would eradicate the diseased tissue entirely.
Still, many more operations and treatments would be needed.
April 20, 2004:
Surgery No. 11
Working with a dozen others, Suen prepared to take skin from behind Oliveira's left ear and graft it under her right eye, which had sunken from lack of muscular and skeletal support in her paralyzed cheek. He would zap surface malformation on her cheek and, he hoped, attack the collagen-like growth in her lips. Finally, he would close the gap at the corners of her mouth to eliminate the perpetual snarl on the paralyzed right side and close the hole in her palate with borrowed tissue.
First going after regenerated malformation around Oliveira's right eye, Suen saw just a sliver of blood, then more as it filled what was once a tear duct.
A suction tube drew blood away while Suen held her skin with a tweezers and prodded with a pen-like tool. As he sewed on a sliver of skin from her neck, Oliveira suddenly opened her eyes.
"You're doing fine, great," the doctor reassured her.
"Be very still -- we're still working," Suen said. To a nurse, without looking, he said calmly, "Elevate her eyelid to protect her eye better."
"I want to sleep," Oliveira said fuzzily.
"Almost finished," Suen reassured.
"Finished?" she trailed off.
The operations to this point were successful enough that Suen readied for the final stage of reconstruction.
Then, unexpectedly, the process was put on hold.
CASSI, Oliveira's insurance company in Brazil, withheld coverage. Two company doctors had initially authorized complex procedures performed by Suen, saying her Brazilian surgeons could not do them. Once laser treatments began, CASSI and Suen disagreed on whether her AV malformation still threatened her life.
As lawyers wrangled over who would pay -- Suen said total treatment could cost $1 million -- Oliveira's condition worsened.
She appealed to CASSI and to the world at large on a Web site, seeking donations.
"I have dreams," she wrote, "and my biggest dream is the dream of life."
In the end, three things happened: The Little Rock medical school agreed to absorb costs associated with Oliveira's treatment, if necessary; Brazilian government funds were found; and finally a court in that country ordered CASSI to pay.
The insurance wrangling lasted two months. Through it all, the irrepressibly bubbly Calixto tried to keep their spirits up.
"We won't whine," she said. "If you think negative, you become negative."
But more bad news lay ahead.
An arteriogram in May 2004 showed a cluster of black tangles lurking below Oliveira's skin. The angry malformation was back, and reached to the base of her skull.
July 14, 2004:
Surgery No. 12
This one would determine, Suen believed, whether Oliveira had a chance of defeating the malformation for good. But it was risky. If the disorder was too deeply entrenched, she could bleed to death.
For the first eight hours of the procedure, Suen cauterized spewing blood vessels and plucked them from the inside of her head.
Deftly, he wielded his cauterizing instruments -- equal parts destruction and healing. One tool looked like a flat-headed screwdriver with a handle switch to heat the metal tip.
Suen pushed balls of wax down hard to stem the flow of blood along her eye socket and sinus wall. Her cheek was a lifeless flap.
"Her eyes are at risk right now," he said, 12 hours in. "These are big vessels, but it's hard to tell where the disease stops and the virgin tissue begins."
"We're really down in there." Oliveira was bleeding so much, he said, that her life hung in the balance.
At last, as evening fell, doctors placed processed cadaver tissue in her face to give it needed bulk.
Eighteen hours and they were finally finished. Suen was exhausted.
"She does okay with big operations -- her face actually looks better now," he said. "I, however, don't look so good."
Amazingly, two days after the surgery, Oliveira was talking, oh so softly. Her face looked like a patchwork soccer ball from the streets of Sao Paulo. But she was alive.
With Oliveira's bleeding seemingly under control, Suen proceeded with smaller operations over several months to rebuild her face.
Its shape became less concave, and tissue around her failing right eye became tighter and stronger. The opening of her mouth became more natural. But Suen found and removed more malformation.
"It always looks good when I finish and then it doesn't heal," he said last November.
A month later, something new happened: Oliveira complained about how she looked after reconstructive surgery. Then a February operation brought complaints about the curvature of her mouth. A later skin graft left her distraught.
"It looks like I have big eye, monster eye," she groused.
"I don't blame her," Suen said. "If she weren't an advocate for herself, she'd be dead."
Another shift was becoming apparent. For the first 20 months of her stay, Oliveira spoke regularly about going home. Now that a date had been set for her return -- April 22 -- she sought reasons to stay in Arkansas.
"In Brazil, they experiment on me," she said. But not Suen.
Suen tried to reassure her that a colleague in Brazil could help. Getting on with her life was best, he said.
As she and her mother finished packing their apartment, Oliveira brightened. Her attitude started to improve when she received three botox injections on her left side to weaken the healthy face muscles and bring them more in balance with the paralyzed ones on the right.
Her mother had taken pictures throughout their stay, and they showed the dramatic change in Oliveira's face.
Her daughter's goals had evolved, too. Instead of wanting to simply survive, Rafaella Oliveira said she also wanted to look her best. And she retained her original dream of helping others overcome the anxiety of having a disfiguring disease.
On one of her last visits to Suen's office, she handed him some legal documents. She asked him to write that her treatment was not complete and that she would need to return to Arkansas in six months.
"That's what you want me to say," he said, chuckling sheepishly.
"What then -- a year?" she prodded.
"Sure. A year will be fine," he relented.
She will continue to need treatment, here or there, Suen said. But she needed a break.
Oliveira looked ahead with her old optimism.
"With six months, a year, no surgeries," she said, "who knows what can happen?"