Last month Patrick Hardison hit a major milestone in his life.
It had been one year since the Mississippi volunteer firefighter underwent one of the world's most extensive face transplant surgeries.
Fifteen years ago Hardison suffered massive burns to his face when the ceiling of a burning house collapsed on him. He lost his eyelids, lips, ears, and most of his nose.
At the time of the face transplant, surgeons gave him a 50 percent chance of surviving the procedure, according to a story in Time magazine.
But today Hardison is alive, and so far the potent drugs that he takes have prevented his body from rejecting his new face.
Hardison's impressive progress during the past year is not just a personal milestone. But also one for the field of face transplants, which, with fewer than 40 transplants under its belt, is still in its infancy.
Technique continues to improve
Of course, transplanting a face is no small feat.
Hardison's surgery lasted 26 hours and included a team of more than 100 doctors and other healthcare staff.
Each surgery is also unique, with every patient presenting different challenges.
"The team needs to train together -- much like a rocket launch -- so things go very smoothly and there are no hiccups in the technical aspect," Dr. Frank Papay, chair of the Cleveland Clinic's Dermatology and Plastic Surgery Institute, told Healthline.
Cleveland Clinic has already done two face transplants and has a third one coming up.
But although face transplants are still relatively new, this exhausting procedure has come a long way since the first partial face transplant in France in 2005.
"Technically, the field has advanced to be more intricate and to involve more of the face, where now we're doing near-total or total face transplants," said Papay.
In the future, the technical aspects of face transplants will continue to progress along the same trajectory, with doctors sharing what they learn.
The real challenge going forward will be to keep the recipient's body from rejecting the transplant.
"The research on the technical end has been said and done, and continues to advance very quickly," said Papay, "but the research in the promise of complete tissue tolerance from allografts is not quite there yet. That's the goal."
Organ rejection happens when the recipient's immune system attacks the new tissue as "foreign." This is not unique to face transplants, but can also happen with hearts, livers, and kidneys.
To prevent this, doctors try to match the tissue of the donor and the recipient as closely as possible.
After surgery, recipients take powerful drugs -- for the rest of their lives -- that suppress their immune systems. But these drugs are linked to a higher risk of heart disease, serious infections, and a shorter lifespan.
Hardison was also given the monoclonal antibody Rituximab before surgery to prevent a type of white blood cells, called B lymphocytes, from attacking the transplanted tissue. Even this is not perfect.
Finding something that works better is what Papay calls the "Holy Grail" for making face transplants more successful.
Public acceptance grows
In the early days of face transplants, many people thought it would be like the movie "Face Off," with Nicholas Cage and John Travolta.
But there was also a great deal of concern over the procedure. One study found that opinion about these procedures leaned toward "outlandish" or "morally objectionable."
But those views have subsided as more successful face transplants have been done.
"There has been a shifting landscape of ethical concern over [face transplants] as we gain more information about how transplants are conducted and how the patients experience the procedures," Christopher Scott, Ph.D., M.A., a senior faculty and associate director of health policy at the Center for Medical Ethics and Health Policy of Baylor College of Medicine, told Healthline.
Part of this has to do with the reality of face transplants being much different from what you might see in a movie.
"[What] we've learned from the two face transplants that we've performed here at the Cleveland Clinic," said Papay, "is the new face is not like the donor's face. It's not like the recipient's face. It's a mosaic of both."
But opinions have also shifted as the public has seen how much the procedures can transform the lives of patients.
After his surgery, Hardison could go out into public again without being stared at. He even took his five children to Disney World in Florida and was able to swim with them for the first time since the accident in 2001.
Changes in public opinion have occurred with other technologies, such as putting pig valves into the hearts of people with heart disease.
"As these moved into generalized medical practice -- I mean, we do thousands of these procedures every year -- no one even thinks twice about it," said Scott.
The real transformation of the field may happen if the government and health insurance companies start covering the costs of the procedure. A face transplant can cost up to $1 million.
"I think [Medicaid and Medicare] will gradually move into accepting this, but I think [they] would want to wait until there's even a few more patients," said Papay, "But I think we're on that cusp right now."
When that happens, more people will be able to benefit from the procedure, not just those whose face was injured in an accident. Recipients could include people who had part of their face removed because of cancer and those born with congenital face defects.
It's hard to know what society will think about face transplants in the future, but if the current trends continue, the "wow" factor may take a back seat to the people helped by the procedure.
"If the path of movement is any indication of what we can expect in the future, then we may see some of the same thing," said Scott, "away from the worries about whether a person would somehow lose their identity if they had someone else's face to more concern about the individual health of the person."
By Shawn Radcliffe