The following version of the novel was used in the creation of this study guide: Ruhl, Sarah. Smile: The Story of a Face. Simon & Schuster. 2021. Hardcover.

While the author does spend a majority of the memoir reflecting on the past, she occasionally ponders questions in the present tense or refers to studies that took place after her experiences.

The narrator, Sarah Ruhl, says her story began years ago shortly before the performance of her first written Broadway play "In the Next Room" when she discovered she was having twins. While she was excited, she also worried that something would happen to them or that she would never be able to write again. She read a fortune telling her to deliver what she had for it would save her life, but Sarah did not know what it meant. Then, after a great opening night, Sarah realized she was bleeding and her doctor demanded that she stay home until the birth. Due to this, Sarah researched the Victorian treatment known as rest cure where women suffering from various maladies such as pregnancy or hysteria were required to isolate themselves in bed with no hobbies and little human contact.

Around the sixth month of pregnancy, Sarah learned she had cholestasis of the liver and was forced to get frequent ultrasounds to monitor the children. When her symptoms increased, the doctors gave the twins steroids to hasten the development of their lungs before inducing labor. Sarah gave birth to William and Hope, but was diagnosed with Bell's palsy; a neurological disorder in which half of the face is paralyzed. William and Hope were also taken to the NICU for seven days.

After explaining how she believes in God but is no longer a part of the Catholic Church, Sarah writes that she prayed for her children. When they came home, she struggled to handle both newborns and her three-year-old Anna at the same time. Her Bell's palsy also caused significant pain and sensitivity to sound, but her mother-in-law Liz, her own mother, and the family caregiver Yangzom all helped. Meanwhile, Sarah hated when people demanded that she smile. Then, she discusses how women are often expected to smile when men ask them to

Three months after the twins were born, Sarah attended the opening of her play called “Passion Play” with her mother. She explains to the reader that this play was the first she started 12 years prior when her teacher, Paula Vogel, convinced her to turn her idea into her senior thesis. Encouraged by her mother's love of acting and the performance of the first act at a festival, Sarah decided to become a Playwright. At the opening, she was pleased with the performance, but hid afterward because she was ashamed of her inability to smile.

Months went by and Sarah's condition did not improve despite the numerous treatments she tried. Furthermore, she struggled with her children and worried that she was slowing down their emotional progress because she could not smile at them. This threw her into a deep and prolonged depression as she struggled to feel random joy when she could not spontaneously express it. This led her to think about the idea of asymmetry within the standards of beauty.

A year and a half after the birth of the twins, Sarah was asked by Paula to teach at Yale School of Drama. This gave Sarah newfound connections to fellow writers including Max, a terminally ill student whose love of writing reminded Sarah why she loved writing. Around this time, Sarah learned that her recovery was slow due to Celiac disease. Sarah saw this as a chance to let go of her own feelings of guilt and used this knowledge to help Anna when she was also diagnosed.

However, Sarah's depression got progressively worse until she struggled with extreme feelings of anger, self-hatred, and inadequacy. She never told anyone, convinced that she had too good of a life to be depressed. Her husband Tony eventually convinced her to talk to a professional, and Sarah contributed the start of her recovery to an amazing psychiatrist. Over time, she spoke to many different theologians and Buddhist monks including Lama Pema who encouraged Sarah to write, meditate, and find refuge in her beliefs.

After discussing how important it is to empathize with others as well as the meditation she needed to overcome her father's death many years prior, Sarah shifts to nine years after the birth. She learned she had synkinesis, or a disorder in which some muscles move when they are not meant to. She met another Bell's palsy sufferer named Jonathan who convinced her to find compassion for herself.

After rejecting a potential Botox procedure, Sarah decided to work with a physical therapist named Elaine. Within a few months. Sarah overcame her shame and found herself smiling and laughing without trying to hide her face. In November of 2019, Elaine declared the death of Sarah's first synkinesis.

Sarah then tells the story of her father's death and how he sought to keep his family's spirits high in spite of it. Sarah highly values everything her father taught her and looks for the possibilities she has in the life she has. In the final chapter, she admits that her story is not as exciting as others, but it proved to her that she is good enough for love and that one should not strive for perfection. She ends with a prayer for the healing of others.