McKinnon explained early on to Mestre and his sister the pros and cons of a facial transplant versus standard surgery.
"Standard surgery done by experienced craniomaxillofacial surgeons is still the preferred pathway to success," he said. "There are very serious risks of allotransplantation that may not be fully appreciated by the public."
The risks include acute and/or chronic rejection; need for permanent immunosuppression of the immune system; death by infection; and higher risk of malignancy.
Also, notes McKinnon, the medical alternatives to transplant failure are still not addressed.
"They cannot go on heart assist with a device, they can't receive another face transplant in all likelihood, and they can't go on renal dialysis, the alternative for kidney transplant failures, " he said.
At his recommendation, the Mestres decided to go ahead with surgery.
McKinnon and his colleagues performed three procedures over the course of three months. The first, done in July, entailed a tracheostomy to give Mestre a protected airway and removed 98 percent of the tumor.
In the second surgery, doctors took out a small residual portion of the tumor and began reconstruction of his mouth and nose. An additional tumor on his tongue was also removed.
In a third procedure, doctors fed a nasal gastric tube into Mestre to maintain proper nutrition. They repaired skin tissue that had broken down after the two previous surgeries.
"The skin had good arterial input, but the venus return was inadequate," said McKinnon.
Although Mestre's facial skin looks raw, McKinnon said, "it takes a lot of time to resume color, texture and shape."
Doctors hope that he will be able to have additional reconstructive surgery in Portugal, where Mestre and his sister returned in the fall.
"They didn't want to be here indefinitely," said McKinnon. "She had to make a living and run the hairdressing shop. It was time for them to get back."
Today, Mestre's post-operative face looks much like a burn victim. Nevertheless his life "has really changed," according to Schafer.
"He never wanted to leave the house, but now he goes outside every day, singing," she said. "It's really remarkable and Dr. McKinnon is a remarkable surgeon."
Although McKinnon deems surgery a success, Jose has a long road ahead, especially psychologically.
"Despite how hard it may be for some people to understand, anyone who has lived with something like this for 40 years has a hard time letting go of it," he said. "And what the future holds can be more anxiety provoking. He had been very anxious about surviving the surgery and had been told by his doctors he would die. It was a wrenching experience for him."
Still, McKinnon said the tumor is not likely to grow back and Mestre's future holds promise. He may need minor surgery to his gums or tongue, but he is not longer in danger of losing his life.
"They are pretty sky-high right now," he said of the Mestres. "He needs more psychological recovery, but I have done what I can to guide them. Inevitably this is not something that one recovers from in a matter of months. It may take years to make a full recovery.
"But right now, he is elated to go out and not be the subject of undo attention or scorn."