plastic-surgery

CLINIC APPEARANCE MASKS PROBLEMS FACING SURGEON\ Sun-Sentinel - Sunday, July 12, 1998\ Author: FRED SCHULTE and JENNI BERGAL Staff Writers\ The American Institute of Plastic Surgery in Fort Lauderdale takes up\ the entire fifth floor of the Savings Bank of America Building on\ North Federal Highway. Elevators open directly into a waiting room\ decorated with a china-white statue of Venus, the goddess of beauty.\ \ The clinic\'s chic appearance gives no hint of the bitter financial\ disputes pending in court between institute medical director Jerry C.\ Lingle and his creditors and investors, or of his troubles with the\ state, which wants to revoke the surgeon\'s license.\ \ \"I don\'t get the impression they [the clinic) are carrying on business\ as normal,\" said attorney Grover Freeman, who represents the surgeon.\ \ Lingle is fighting a state order suspending his medical license amid\ allegations of incompetence.\ \ He\'s also facing lawsuits that accuse him of failing to pay investors,\ creditors and a judgment against him. Lingle declined to discuss his\ business affairs, but in court filings he denies any wrongdoing.\ \ Lingle opened the plastic surgery institute in June 1996 partly\ through a \$100,000 loan from a trust represented by Vivian\ Regenstreif, who lives in Hollywood. To repay the loan and interest,\ Lingle made monthly payments of \$2,000 out of the proceeds from the\ institute.\ \ But in November 1997, the trust sued, claiming Lingle had breached the\ agreement by failing to make timely payments. As of April, the trust\ claims it is owed \$101,043, court records state. Vivian Regenstreif\ declined to comment on the lawsuit.\ \ Lingle has sued a management company under contract to run the clinic,\ alleging embezzlement. The management firm, Total Concept Management\ Group, disputes Lingle\'s account and accuses the surgeon of improperly\ withdrawing more than \$35,000 from its account. The suit is pending.\ \ In yet another lawsuit, an Indiana company claims Lingle reneged on a\ lease agreement for an \$18,000 office video imaging system.\ \ Lingle leased the equipment in 1991 when he was practicing in\ Kentucky, but stopped making payments after he moved his practice, and\ the leased equipment, to Fort Lauderdale, according to the suit. The\ company seeks to repossess its gear and wants at least \$54,560.70 in\ damages and interest.\ \ In a separate case, the state of Mississippi is seeking to garnish\ Lingle\'s wages to satisfy a tax judgment of \$142,365, court records\ state. Mississippi officials said state law prohibits them from\ discussing a taxpayer\'s case.\ \ And attorney Richard Woulfe, who represents Lingle in several medical\ malpractice actions, is trying to quit. Woulfe has filed court papers\ asking a judge to let him withdraw as Lingle\'s counsel, citing\ \"irreconcilable differences\" with his client.\ \ If Woulfe quits, it is likely to postpone resolution of malpractice\ suits pending against Lingle. Broward court records show Lingle is\ named as a defendant in eight cases alleging negligence beginning in\ 1996.\ \ The Florida Physicians Insurance Company canceled Lingle\'s medical\ malpractice insurance as of July 11, 1996, for reasons listed as\ \"unknown\" in a letter to state medical officials.\ \ State law requires doctors to have either a liability policy or\ demonstrate that they have the means to satisfy a judgment of up to\ \$250,000.\ \ Lingle claims in court filings that the policy was canceled because\ his management company failed to pay the premiums on time. In a March\ 1998 deposition, Lingle testified that he got a new malpractice policy\ with a different insurance company in about November 1997.\ \ SURGEON\'S HISTORY EXPOSES FLAWS\ Sun-Sentinel - Sunday, July 12, 1998\ Author: FRED SCHULTE , MARY C. WILLIAMS and JENNI BERGAL Staff Writers\ Marie \"Maggie\" Bellabe went to the American Institute of Plastic\ Surgery to have fat removed from her body and ended up in an intensive\ care unit. Her dramatic case finally prompted Florida\'s medical\ licensing board to take action against plastic surgeon Jerry Lingle.\ His history includes at least six complaints to the state and eight\ lawsuits alleging medical malpractice.\ \ Bellabe crawled out of Lingle\'s Fort Lauderdale clinic a few hours\ before dawn on April 1, dragging her medical equipment behind her, and\ collapsed on the sidewalk. A cabdriver who found her called police.\ \ For the next five days, Bellabe was in intensive care at Holy Cross\ Hospital, recovering from injuries state officials blame on botched\ liposuction, a surgical procedure to remove fat.\ \ More than seven weeks later, the Florida Department of Health\ suspended Lingle\'s license with an emergency order, citing negligence\ or poor medical care in Bellabe\'s case and five others that records\ show were reported to the state as early as 1996.\ \ A hearing on his license scheduled for Monday was canceled late Friday\ as state officials negotiated a possible settlement with Lingle\'s\ lawyer. But a state health agency spokesman said the emergency\ suspension remains in effect until the Board of Medicine takes up the\ case next month.\ \ \"We are going to vigorously defend the charges. There are many flaws\ in the allegations against him,\" said Grover Freeman, a Tampa attorney\ who represents Lingle. Freeman would not elaborate and said he would\ not permit Lingle to speak to the Sun-Sentinel.\ \ In an interview before his license was suspended, Lingle said his\ clinic meets specifications. \"This is not a shabby facility,\" he said.\ \"We meet all the standards that are required.\"\ \ Whatever its outcome, Lingle\'s case points to shortcomings in the\ state\'s system for overseeing plastic surgery performed in private\ doctors\' offices and clinics. Florida doctors performed at least 9,700\ liposuctions last year, almost all of these outside hospitals,\ according to the American Society of Plastic and Reconstructive\ Surgeons.\ \ Lingle\'s case also demonstrates the state\'s difficulty in alerting the\ public about doctors who are the subject of repeated complaints of\ incompetence.\ \ Department of Health spokeswoman Pam Potter-Ricco said the agency has\ been working to accelerate the investigative process and has been\ lobbying for laws to make complaints more acccessible to the public.\ \ \"There has been a backlog in investigations and prosecutions,\"\ Potter-Ricco said. \"In the last year we\'ve done a very good job in\ speeding up the process. We can now get the cases through faster.\"\ \ Florida\'s Board of Medicine gave Lingle a medical license in June 1994\ despite a criminal conviction, which he did not disclose as required\ on his application, and other past problems.\ \ Since that time, the state health agency has received at least six\ complaints about serious injuries from cosmetic surgery Lingle\ performed, state records show.\ \ The state did not stop Lingle from operating, however, until after\ doctors at Holy Cross Hospital notified officials about Bellabe\'s\ case.\ \ Bellabe and other patients are angry and mystified by the state\'s\ inaction on complaints about Lingle.\ \ \"I don\'t want anyone else to go through what I did,\" Bellabe said. \"I\ want everyone to know what happened to me.\"\ \ Too weak to stand\ \ Bellabe was groggy and gasping for breath when she awoke after\ cosmetic surgery done more than 12 hours earlier at Lingle\'s American\ Institute of Plastic Surgery in Fort Lauderdale, according to the\ state complaint.\ \ \"I couldn\'t breathe,\" Bellabe recalled. She panicked, she said, when\ she called for help and no one answered.\ \ She was too weak to stand, Bellabe said, so she rolled out of her bed\ on the fifth floor and scooted along the floor on her backside,\ continuing to call for assistance. She dragged her intravenous fluid\ hookup, a catheter and heart monitor through the deserted waiting\ room, inching her way toward an elevator.\ \ \"I know Jesus Christ was looking out for me,\" she said. \"He got me out\ of that building.\"\ \ The cabdriver who found Bellabe contacted police about 3:30 a.m.,\ according to state records and Fort Lauderdale fire-rescue and police\ reports. Her surgical garb was bloody, and she could barely speak.\ \ The Florida Department of Health suspended Lingle\'s medical license on\ May 21. The clinic at 4875 N. Federal Highway remains open, though his\ lawyer says Lingle is not practicing while he fights to restore his\ license.\ \ Many of Lingle\'s clients were attracted to the institute by newspaper\ advertisements that promised patients \"the most rewarding buying\ decision you\'ll ever make\" and easy payment plans of \$52 a month. His\ Sun-Sentinel ads described him as \"a master of surgical artistry,\ renowned for great results.\"\ \ Others, like Bellabe, heard about Lingle from friends who had been to\ his clinic. Still, the 225-pound mother of two was reluctant to try\ liposuction.\ \ She reconsidered after a friend paid the clinic \$9,000 for cosmetic\ procedures, which were to include liposuction and a tummy tuck. Her\ friend underwent part of the surgery, but decided not to have the\ rest. Bellabe said she used her friend\'s unused credit to pay for her\ surgery.\ \ Many details of Bellabe\'s experience at the clinic are unclear.\ Lingle\'s account of the surgery and its aftermath greatly varies from\ that of an unlicensed worker who was assigned the responsibility of\ Bellabe\'s care that night.\ \ According to the state\'s medical expert, Dr. Fredric M. Barr, Lingle\'s\ records on the medical history of his patient were \"incompetent and\ incomplete.\" And the state\'s complaint accuses Lingle of failing to\ keep adequate records justifying medical treatment.\ \ Barr, a plastic surgeon in West Palm Beach, concluded after reviewing\ Bellabe\'s medical records that Lingle should not have undertaken the\ five-hour procedure in a medical office to remove such a large volume\ of fat.\ \ Barr also criticized Lingle\'s medical decisions. Lingle\'s notes\ indicate he administered 4,000 milligrams of the anesthetic drug\ lidocaine during surgery, some 1,600 milligrams more than the maximum\ recommended dosage, the state complaint says.\ \ Excising such a large mass of fat and using that much lidocaine in\ surgery \"posed a grave risk of fatal complications,\" Barr concluded.\ \ A toxic reaction to the drug caused Bellabe to suffer seizures after\ she dragged herself out of the empty recovery room and made her way to\ the street, according to the state complaint.\ \ Lingle was unable to care for Bellabe at Holy Cross because he lacks\ privileges to treat patients there, Barr said in his report.\ \ Lingle also lacks hospital transfer privileges that allow transport of\ patients to a nearby hospital in case of emergency. The state requires\ doctors who do complicated surgical procedures in their offices to\ have staff or transfer privileges.\ \ Critical gaps in Bellabe\'s medical records, Barr wrote, \"make\ follow-up care by another physician highly problematic and potentially\ dangerous.\"\ \ Lingle disputes Barr\'s findings. In an interview before the state\'s\ action against him, Lingle said he had been doing large-volume\ liposuction for several years without serious complications. He denied\ that Bellabe\'s problems stemmed from his techniques.\ \ The surgeon said Bellabe\'s ordeal was due to caused by his former\ employee, Paetraze Lopez, who he said abandoned Bellabe in the\ fifth-floor clinic. \"It was a very, very unfortunate thing,\" Lingle\ said. \"But it would not have happened if the nurse had been there.\"\ \ The state complaint accuses Lingle of permitting an unlicensed person\ to administer drugs and of failing to supervise her properly. Lingle\ said he didn\'t know until after the Bellabe incident that Lopez had no\ state nursing license.\ \ Lopez confirmed in an interview that she lacks a nursing license, but\ she denied leaving Bellabe alone that night. She said she was in\ another room and never heard Bellabe call out.\ \ \"I did not leave her,\" Lopez said. \"If she was yelling, I think I\ would have heard her.\" Under Florida law, practicing nursing without a\ license is a first-degree misdemeanor.\ \ Gap in affiliations\ \ Jerry C. Lingle, 61, was a plastic surgeon in Hopkinsville, Ky., when\ he applied for a Florida medical license in January 1994, state\ records show. Because he held a valid license in another state, Lingle\ was eligible for a Florida license after he completed an application\ and provided a full accounting of his training and experience since\ medical school.\ \ Lingle\'s medical record spans 25 years. He graduated from the\ University of California at San Francisco School of Medicine in 1969.\ He served a one-year fellowship in plastic surgery at the Phoenix Area\ Indian Health Service Medical Center beginning in July 1976, according\ to the center\'s former chief.\ \ Since graduation, he has held medical licenses in Mississippi,\ Kentucky, Connecticut, California, Pennsylvania, Virginia and Florida.\ Only the Virginia license remains active, and it expires in September,\ according to officials in that state.\ \ Typically, Florida medical regulators review a doctor\'s application\ and check professional references before recommending approval. Lingle\ wrote to medical boards in the other states asking them to forward to\ Florida verification that he had been licensed.\ \ But Lingle did not account fully for more than 32 months between\ January 1986 and August 1988, a time when he let his Kentucky medical\ license expire. He later renewed it.\ \ Reviewers at Mary Immaculate Hospital in Newport News, Va., noticed\ the gap. The Virginia hospital denied Lingle staff privileges in April\ 1991, partly because of the \"substantial gap\" in hospital affiliations\ from May 1985 to July 1988, \"which were not satisfactorily explained,\"\ a hospital official told Florida regulators in a 1991 letter.\ \ The 32-month period for which Lingle didn\'t fully account coincides\ with an investigation of his medical practice in Kentucky. That\ inquiry began shortly after a patient died during a nose job in July\ 1985, Kentucky records show.\ \ The patient, Kenneth Lester Lewis, 22, was a female impersonator and\ Louisville cabaret entertainer who took the stage name Kay Bell Fox.\ \ Earlier, Lingle had inserted breast implants in Lewis\' chest, which\ became infected, according to Kentucky records. While correcting that\ problem, Lingle did a rhinoplasty, or nose job. Fox died on the\ operating table in Lingle\'s office.\ \ The local coroner called an inquest, which found that Lewis died from\ a toxic reaction to an anesthetic drug and from choking on blood that\ backed up in his throat and stomach during surgery. The inquest jury\ also accused Lingle of negligence, according to state records.\ \ The Kentucky Board of Medical Licensure in December 1985 accused\ Lingle of failing to monitor the patient\'s condition \"properly during\ the course of the surgical procedure.\"\ \ While the Kentucky Medical Board\'s case against Lingle was pending,\ Lingle in February 1988 settled a private malpractice lawsuit brought\ by the family of the cabaret singer for \$35,000, Kentucky court\ records show.\ \ Two months later, a state hearing officer ruled that Lingle had failed\ \"to conform to the standards of acceptable and prevailing medical\ practice\" in Kentucky. Lingle did not \"continuously monitor his\ patient while under anesthesia, which resulted in an apparent sudden\ loss of the patient\'s vital signs,\" according to the ruling.\ \ The Kentucky medical licensing board voted in May 1988 to \"monitor\"\ Lingle\'s medical practice, which the state did not consider to be a\ disciplinary action. That ended the investigation, and Lingle was\ cleared of the charges.\ \ Arrested in Philadelphia\ \ During the mid-1980s, Lingle was not practicing medicine, according to\ a statement he filed with Kentucky\'s medical board. He had moved from\ Kentucky to Philadelphia, where he was president of a telephone-sales\ business called Tela Marketing Communications, court records show.\ \ That job led to his arrest in November 1987. Pennsylvania prosecutors\ charged him with 15 counts of failure to remit sales taxes of more\ than \$75,000 due for that business. Lingle \"used these funds in the\ general operation of the business and continued to draw a large\ personal salary,\" reads an affidavit filed by a state investigator.\ \ Nearly a year later, a jury convicted the physician on 12 criminal\ misdemeanor counts. He was sentenced in December 1988 to six months\'\ probation and ordered to pay \$12,000 in fines, according to court\ records. By then, Lingle was back in Kentucky in a new medical\ practice.\ \ In April 1994, Lingle appeared before the Kentucky board and\ \"requested that he be removed from `monitor\' status, noting that he\ planned to move to Florida,\" according to minutes of the meeting. The\ board agreed.\ \ Details omitted\ \ Lingle omitted details about his past when he applied for a Florida\ medical license in 1994. He answered \"no\" to a question asking if he\ had ever been convicted of a misdemeanor, Florida records show.\ \ While the tax convictions might not have been grounds for barring\ Lingle from practicing medicine, misstatements on an application are\ grounds for denying the license in the first place, said health\ department spokeswoman Potter-Ricco.\ \ James Peterson, general counsel for the Florida Department of Health,\ said confidentiality provisions in state law constrain the agency from\ commenting on a case. The state does not routinely check all\ information a doctor submits on an application.\ \ Health department spokeswoman Potter-Ricco said of Lingle\'s\ conviction: \"We didn\'t have any knowledge of that. It\'s something we\ need to look into.\"\ \ Within a year of Lingle\'s arrival in Florida, signs of trouble\ surfaced. Under state law, lawyers intending to file medical\ malpractice lawsuits must first notify the state health agency in\ Tallahassee. The process is supposed to help state regulators\ investigate misconduct or negligent care by doctors.\ \ State records show that allegations of disastrous results in patients\ under Lingle\'s care arrived in Tallahassee only to sit for a year or\ more after attorneys filed them. State officials refused to release\ copies of the letters, citing confidentiality laws.\ \ But court records show that the state received such notices as early\ as June 1996.\ \ While the state complaint accusing Lingle of incompetence lists six\ cases, court records also show eight malpractice lawsuits have been\ filed against Lingle in Broward Circuit Court in the last two years.\ \ One was filed on behalf of Elfrieda Compton, 64, of\ Lauderdale-by-the-Sea, who went to Lingle for a face-lift in May 1995.\ \ \"I went in and had the surgery. When it was over, I found out I\ couldn\'t close my eyes, especially my left one, for about the first\ six months. I still can\'t close it totally, \" she said in an\ interview.\ \ Compton, who is cited in the state complaint against Lingle, said she\ still has pain and trouble breathing as a result of the surgery. In\ court papers, Lingle has denied negligence.\ \ Compton is angry state officials didn\'t open an investigation into her\ complaint until November 1997, more than two years after her\ operation.\ \ \"In the first place, the state was negligent because they gave him a\ license,\" she said. \"And I don\'t think it should have taken them three\ years to act, with all those complaints against him.\"\ \ Andrea Hershewe, 53, a former crossing guard with the city of\ Deerfield Beach, also complained to the state and filed a lawsuit\ accusing Lingle of negligence.\ \ She hoped a face-lift in October 1994 would rejuvenate her, but the\ surgery left her paralyzed on the right side of her face, Hershewe\ said, leaving her unable to close an eye. Lingle has denied her\ allegations.\ \ \"I\'m lucky I\'m alive at this point,\" Hershewe said in an interview.\ \"But it\'s something I have to live with for the rest of my life.\"\ \ Tania Martinez, 29, who works for a mortgage company and lives in\ Sunrise, claims Lingle disfigured her during breast enlargement\ surgery in July 1995. Court records show that state officials\ acknowledged receiving her complaint of malpractice in June 1996.\ \ \"I think [the state investigation) took a long time,\" said Loreen\ Kreizinger, who represents Martinez in a lawsuit pending against\ Lingle, who has denied her allegation in court filings.\ \ Department of Health general counsel Peterson said the agency\ unsuccessfully lobbied for a bill, defeated last session, that would\ have allowed the public to find out about active investigations\ against doctors or other professionals, as long as the disclosure\ wouldn\'t hurt the investigation.\ \ \"State law puts a clamp on what we can say,\" Peterson said. \"We\'ve\ tried to open up the process.\"\ \ Lingle has apparently won at least one early victory in his battle\ with the state to restore his license.\ \ In late June, Lingle\'s attorney said the state had dropped four counts\ alleging that Lingle lied about his disciplinary history in Kentucky\ on his application for a Florida license and when he sought hospital\ privileges at the Cleveland Clinic Hospital in Fort Lauderdale. State\ health officials said they could not comment about whether the charges\ were dropped.\ \ The credentials committee at the Cleveland Clinic Hospital in July\ 1995 had reported to the state that Lingle\'s request for privileges\ was denied because of a \"significant misstatement\" on his application,\ where Lingle said \"he had never had his license limited.\"\ \ Lingle checked \"no\" to a question on his Florida license application\ about previous restrictions on his practice, too, leading the state to\ add a charge of \"fraudulent misrepresentations.\"\ \ But Lingle attorney Freeman pointed out to Florida officials that\ Kentucky\'s decision to \"monitor\" Lingle\'s practice did not constitute\ disciplinary action under Kentucky law. Therefore, Lingle was truthful\ in his application.\ \ \"He fully disclosed his status,\" Freeman said. \"Everyone is satisfied.\"\ \ Faces more charges\ \ Lingle still faces other state administrative charges involving\ Bellabe and the five other patients. His continued practice of\ medicine \"constitutes an immediate and serious danger to the health,\ safety and welfare of the public,\" according to the state\'s complaint.\ \ Freeman said on Friday that he expected the case to be settled without\ a hearing. He declined to discuss the terms of the possible\ settlement. The board of medicine still must decide whether to accept\ any settlement worked out between Lingle\'s lawyer and the state. The\ board can restore Lingle\'s license, revoke it, or impose a fine or\ other penalties.\ \ Bellabe hopes Lingle will never again be allowed to practice plastic surgery.\ \ \"I still can\'t sleep. I keep dreaming that I\'m being taken to a dark\ room with black sheets and I can\'t breathe,\" she said. \"Then I wake up\ screaming.\"\ \ FOR THESE PATIENTS, THE ULTIMATE PRICE\ Sun-Sentinel - Sunday, November 29, 1998\ Author: FRED SCHULTE AND JENNI BERGAL STAFF WRITERS\ Most plastic surgery goes smoothly and patients are happy with the\ results. But complications, including crippling injuries and deaths,\ can occur. Here are the stories of some Florida patients who died\ after cosmetic surgery in recent years:\ \ Shannon LeGue Age: 25 Home: Palm Beach Gardens Procedure: Breast\ enlargement Date of death: March 21, 1995 LeGue, a former waitress and\ divorced mother of a toddler, hoped bigger breasts would make her\ sexier looking. Though her fiance, Ron D\'Amico, had reservations, he\ paid Jupiter plastic surgeon Mark Prysi \$3,925 for breast implants.\ \ After more than six hours of surgery, D\'Amico drove LeGue home. She\ complained of pain and was very groggy, but was able to walk on her\ own, according to Palm Beach County Medical Examiner\'s Office records.\ By 8 p.m., she could not get out of bed. D\'Amico said he gave her a\ pain pill and she went to sleep. At 4 a.m., D\'Amico awoke to find his\ fiancee lying on her side, cold to the touch. He called paramedics,\ who took her to Palm Beach Gardens Memorial Center, where she was\ pronounced dead.\ \ The Medical Examiner\'s Office ruled LeGue\'s death an accident caused\ by \"complications of breast augmentation,\" but offered no further\ details. Prysi, who has since moved his practice to Naples, denied any\ responsibility in court documents for LeGue\'s death. His lawyer said\ in a May 1995 letter that LaGue\'s death was \"in no way related to the\ surgery.\"\ \ The letter was written to D\'Amico\'s credit card company after D\'Amico\ argued, unsuccessfully it turned out, to have the charges for LeGue\'s\ plastic surgery taken off his bill.\ \ D\'Amico remains bitter about LeGue\'s death. \"It was devastating, to\ say the least,\" he said.\ \ LeGue\'s family settled a lawsuit against Prysi for \$350,000 in March 1998.\ \ Prysi did not respond to requests for comment.\ \ His office manager, who said her name was Danielle but would not give\ her last name, said the surgeon is \"not interested\" in commenting on\ LeGue\'s case.\ \ Daniel Parish\ \ Age: 51\ \ Home: Lantana\ \ Procedure: Liposuction, penis enlargement, face-lift\ \ Date of death: Jan. 13, 1998\ \ Parish wanted to be rid of wrinkles, jowls and other signs of age on\ his eyelids, neck and face. Parish also wanted Dr. Mark Schreiber, a\ Boynton Beach plastic surgeon, to suction out a small amount of fat\ from the \"love handles\" around his waist and use it to enlarge his\ penis, medical records show.\ \ The surgery took place in Schreiber\'s office from about 8:30 a.m until\ after 6 p.m. and seemed to have gone fine. Parish was scheduled to\ spend the night in Schreiber\'s office and be cared for by a nurse from\ a private agency.\ \ Things started to go wrong just after Schreiber left for the night.\ First, a nurse noticed about 8:30 p.m. that Parish\'s oxygen tank was\ empty and he was \"in distress,\" according to the medical examiner\'s\ records. The nurse called her office to ask for guidance, but\ paramedics were not contacted until about 9:02 p.m. Rescue workers\ took Parish to Bethesda Memorial Hospital, where he was pronounced\ dead at 10:07 p.m.\ \ The Palm Beach County Medical Examiner\'s Office initially ruled that\ Parish died from heart damage caused by taking a weight-loss drug\ before the surgery. After retesting blood samples, however, doctors\ concluded in July that Parish died of an accidental overdose of\ anesthetic.\ \ Florida\'s Board of Medicine, in an administrative complaint filed in\ June, also said Schreiber erred in scheduling surgery \"of this length\ and magnitude in an office surgical facility.\" Complications \"go up\ directly in proportion to the time of surgery that is required,\" the\ state complaint said.\ \ Schreiber settled the state case in October. He was fined \$5,000,\ placed on probation, required to limit certain cosmetic procedures in\ his office to five hours and have another surgeon review his work. He\ also was ordered to use a licensed doctor to oversee anesthesia in\ most cosmetic procedures in his office. A lawsuit filed by Parish\'s\ widow is pending.\ \ Schreiber would not comment on the case. Instead, he noted that 35 of\ his patients have sent letters of support to the media and state\ officials. \"Those letters speak for themselves,\" Schreiber said.\ \ Bethany Morris\ \ Age: 3\ \ Home: Waverly, W.Va.\ \ Procedure: Removal of facial \"port wine stains.\"\ \ Date of death: Aug. 25, 1990\ \ Bethany\'s parents could not find a doctor in their hometown who could\ use a laser under a local anesthetic to remove the skin discolorations\ known as \"port wine stains\" that covered much of the toddler\'s body.\ The Morrises said they worried that the stains could eventually harm\ their daughter\'s health.\ \ Bethany\'s parents said they felt fortunate when the child\'s\ grandparents, who lived in the Tampa Bay area, saw an advertisement in\ a local newspaper for Dr. Dale Massad, of Palm Harbor.\ \ Massad, a former emergency room physician, performed laser treatments\ on the child beginning in March 1990. The treatments were a\ spectacular success at first, removing most of the stains. But after a\ fourth treatment in the office, which was assisted by a dentist\ because it involved the area surrounding her mouth, the child had a\ seizure and turned blue, according to state health agency records.\ \ No oxygen was available in the office, so paramedics were called and\ took the child to a hospital emergency room. She died three days later\ of what state medical-licensing records describe as \"lidocaine\ toxicity,\" or a fatal dose of the anesthetic drug used during the\ laser surgery.\ \ \"Words cannot explain what this was like for my family,\" said Cheryl\ Ann Morris, a homemaker whose husband runs a trucking company. \"It\'s\ been eight years and it seems like yesterday.\"\ \ Morris took some solace in the fact that state medical-licensing\ officials charged the doctor in an administrative complaint with\ practicing substandard medicine and failing to notice early signs that\ the child\'s life was in danger. In October 1992, Massad agreed to\ surrender his Florida medical license. The family settled a lawsuit\ for \$300,000.\ \ Massad said he was \"totally devastated\" by the child\'s death, the\ first complaint about his competence in 17 years of medical practice.\ He blamed the dentist, whose license was revoked by the state, for the\ overdose, but said he accepted responsibility.\ \ \"I\'m the captain of the ship. That\'s the bottom line,\" Massad said.\ \"If I could be where that child is and let her be alive, I\'d do that.\"\ \ Jeanette Mordica\ \ Age: 44\ \ Home: Miami\ \ Date of death: March 29, 1997\ \ Procedure: Liposuction and tummy tuck\ \ Mordica, an elementary school teacher in Miami-Dade County, didn\'t\ tell her husband she had decided to have a tummy tuck and liposuction\ to remove fat from her thighs and hips.\ \ \"She didn\'t want me to know,\" said her husband, Bernard. \"I would have\ talked her out of it. She wanted to get rid of extra weight and I told\ her to exercise and diet.\"\ \ Dr. Charles Messa III performed the surgery at a Hollywood medical\ clinic. The operation went without a hitch, and Mordica spent the\ night at the doctors\' office, according to medical records.\ \ But the next morning, while watching television, Mordica suddenly\ suffered cardiac arrest. Rescue workers rushed her to Memorial\ Regional Hospital in Hollywood, where she died about an hour later.\ \ The Broward Medical Examiner\'s Office ruled that Mordica died from\ pulmonary thromboemboli, a blood clot that formed in the lungs and\ caused her to stop breathing -- a known complication of both\ liposuction and tummy tuck surgery.\ \ Mordica\'s husband said he is tortured by not knowing exactly how her\ death occurred, and said he thinks this type of surgery should be\ performed in a hospital, never in a medical office.\ \ Messa, who now practices in Tamarac, said Mordica\'s death was\ \"extremely rare,\" a one-in-1,000 occurrence that was impossible to\ predict.\ \ Performing the surgery in a hospital would not have made a difference,\ Messa said. \"This is a thing that can happen.\"\ \ Ronald Jones\ \ Age: 50\ \ Home: Dania\ \ Procedure: Face-lift and eyelids\ \ Date of death: May 12, 1997\ \ Jones figured it was time for a face-lift. He had been fitted for\ eyeglasses and was becoming self-conscious about wrinkles lining his\ eyelids and face, according to his mother. Looks and fitness were\ important to the divorced former railroad supervisor, who worked out\ 45 minutes every day on an exercise machine.\ \ Five hours into the surgery at the Hollywood office of Dr. Richard\ Edison, Jones stopped breathing. Paramedics took him to Hollywood\ Medical Center. For three days, he lay in a coma at the hospital,\ breathing with the help of a respirator before doctors declared him\ brain dead.\ \ Broward County Chief Medical Examiner Joshua A. Perper said Jones died\ of hypoxemic brain injuries and coma, the cutting off of oxygen to the\ brain for reasons that are \"unclear.\"\ \ \"It\'s unbelievable, like a nightmare,\" said Jones\' mother, Rose\ LaVallee. \"You think you\'ll wake up and know this didn\'t happen, but\ it did.\"\ \ Perper\'s autopsy report stated that Jones had \"detectable\" levels of\ the anti-depressant drug Prozac in his body at the time of death. \"It\ is unclear whether higher levels [of the drug) at the time of surgery\ played a role in the death,\" Perper wrote.\ \ Edison said he thinks that Jones\' use of Prozac before the surgery\ contributed to his death. Jones, Edison said, didn\'t tell him about\ his use of the drug.\ \ Edison said he has performed \"many thousands of cases\" without a\ fatality. \"We\'ve made our best effort to build the safest possible\ facility,\" he said. \"It doesn\'t mean the outcome can be guaranteed.\"\ \ Evangelina \'Bonnie\' Dinkins\ \ Age: 44\ \ Home: Miami\ \ Procedure: Liposuction, nose job, tummy tuck\ \ Date of death: Dec. 24, 1993\ \ At 5 feet 4 and 135 pounds, Dinkins decided it was time to have some\ major cosmetic contouring. The part-time Miami-Dade vocational\ education teacher, a divorcee with a young daughter, checked into the\ South Miami Hospital Ambulatory Care Center four days before Christmas\ for liposuction to remove fat from her thighs and hips, a nose job and\ a tummy tuck.\ \ After she was released on Dec. 23, she spent most of her time in bed\ at home but was able to get up and go to the bathroom, according to\ the medical examiner\'s records. But on Christmas Eve, she began to\ have trouble breathing, then fainted and collapsed in the hallway of\ her home and went into cardiac arrest. Paramedics took her to Baptist\ Hospital, where she died.\ \ The Dade County Medical Examiner\'s Office said the cause of death was\ \"massive pulmonary thromboemboli as a complication of plastic surgical\ procedure for obesity.\" Thromboembolism is a clot that cuts off the\ supply of blood and can be a complication of liposuction and tummy\ tucks.\ \ Dr. Alan Serure, a South Miami plastic surgeon who performed Dinkins\'\ operations, said Dinkins\' death was \"inexplicable\" and could not have\ been prevented. \"There was no problem with the surgery. This was very,\ very unusual,\" he said. \"This was a terrible catastrophe. It was a\ tragedy.\"\ \ Florence Carpenter\ \ Age: 66\ \ Home: Flagler Beach\ \ Procedure: Liposuction\ \ Date of death: Sept. 14, 1996\ \ Carpenter wanted to feel better about herself, mainly her figure. Both\ she and her husband felt liposuction to remove some extra pounds from\ her abdomen would be no big deal.\ \ Carpenter, who loved to play golf and paint in her spare time, chose\ Dr. Madhusudan Parikh, of Ormond Beach. Parikh removed 13 pounds of\ fat and skin from Carpenter during the 61/2-hour procedure. She spent\ the night in Parikh\'s office, but the next day required\ hospitalization because of a rapid pulse rate and anemia, according to\ state Department of Health records.\ \ She died at the hospital two days after the surgery from pulmonary\ thromboemboli, the formation of blood clots in the lungs, Department\ of Health records state.\ \ State health officials, in a complaint filed against Parikh in May,\ asserted that the surgeon failed to keep records justifying his\ decision to operate on Carpenter, who had a history of high blood\ pressure. Given her medical history, age, the need for general\ anesthesia and the large amount of fat removed, Parikh should have\ done the procedure in a hospital, the state alleged. The case is\ pending.\ \ Willard Carpenter said both he and his wife of 46 years expected to be\ back on the golf course two days after the surgery. \"It was the\ biggest shock of my life,\" he said. \"We were having such a beautiful\ life together. We had a wonderful time together traveling. We kept\ saying this is too good to last.\"\ \ Parikh would not comment. His attorney, Paul Lambert, said Parikh\'s\ insurance company had settled a malpractice claim by Carpenter\'s\ family for an undisclosed sum.\ \ Lambert said he could not discuss Carpenter\'s case while the\ administrative complaint is pending before state officials. But he\ noted, \"There will be presented evidence to show that Dr. Parikh was\ not the agent responsible for the unfortunate death of Mrs. Carpenter\ and that he acted reasonably and prudently.\"\ \ Enrique Ruiz\ \ Age: 66\ \ Home: Hialeah\ \ Procedure: Face-lift\ \ Date of death: Nov. 16, 1988\ \ Ruiz, a semi-retired exterminator, went to the Palm Springs Surgical\ Center in Hialeah about 11 a.m. to have a face-lift and wrinkle\ removal performed by Dr. Jose Jurado. Two hours later, Ruiz was moved\ on a gurney to a recovery area to recuperate from the surgery and\ anesthesia.\ \ But at 7 p.m., Ruiz was found pale, sweating and having trouble\ breathing. Efforts to revive him failed.\ \ A Hialeah detective investigating the case at the time described the\ center\'s operating room as \"dirty,\" and said he saw \"traces of skin\ and blood around various areas.\" A Dade County Medical Examiner\'s\ Office investigator found \"multiple deficiencies\" in the center\'s\ operating room, including \"filth\" and \"general squalor\" and lack of\ heart-monitoring and emergency equipment.\ \ The medical examiner ruled Ruiz died when the flow of oxygen to his\ brain was accidentally cut off during administration of anesthesia.\ \ Jurado voluntarily gave up his medical license in 1991, following a\ state investigation into Ruiz\'s death. Jurado could not be reached for\ comment despite repeated telephone messages and a letter sent to his\ home.\ \ Grace Boscarello\ \ Age: 63\ \ Home: Clearwater\ \ Procedure: Face-, brow- and neck-lift\ \ Date of death: April 16, 1997\ \ Boscarello, retired from an Ohio trucking business she helped run, was\ enjoying life on the golf course. She hoped a face-lift would make\ life even better, according to her daughter. So she went to the\ Fountain of Youth Institute in Palm Harbor four days after her 63rd\ birthday.\ \ The operation by Dr. C. Randall Harrell went well, except for a period\ when her blood pressure dropped, according to Pinellas County Medical\ Examiner\'s Office records. Boscarello spent the night at the surgery\ office and by 6:30 a.m. was able to drink some water and eat a small\ portion of apple sauce.\ \ Her husband took her home at 7:05 a.m. Seven minutes later, on her way\ into her condominium, Boscarello collapsed on the sidewalk. Paramedics\ took her to a hospital emergency room, where she was pronounced dead\ at 8:21 a.m. The medical examiner could find \"no anatomic cause of\ death.\"\ \ Boscarello\'s daughter said the family was shocked about her mother\'s\ death, considering she appeared to have no serious medical problems.\ \ \"I was so upset. You cannot imagine getting a phone call at 9 o\'clock\ at work telling you your mother has died after a routine face-lift,\"\ said Paula Riggs, of Parma, Ohio. \"People should be very, very aware\ of what is going on. It\'s just not a routine surgery.\"\ \ Harrell could not be reached for comment, despite a letter and\ repeated phone calls.\ \ William Formaad\ \ Age: 71\ \ Home: Pompano Beach\ \ Procedure: Tummy tuck\ \ Date of death: March 10, 1997\ \ Formaad, a speech professor retired from Seton Hall University in New\ Jersey, told friends he was headed to a spa for a little relaxation.\ Instead, he went to South Shore Hospital and Medical Center in Miami\ Beach, where Dr. J. Howell Tiller performed the operation on March 4,\ 1997. Formaad had paid Tiller \$3,500 for the procedure, which he\ billed to a credit card.\ \ Formaad spent the night at the hospital, then two nights at a recovery\ center near Tiller\'s home. Three days after the surgery, he returned\ to his condominium.\ \ Formaad\'s sister, Regina Anfang, said that when her daughter called\ him, he sounded horrible and said he was feverish. Six days after the\ surgery, a friend found Formaad dead in his apartment.\ \ \"It\'s unreal. My poor brother,\" said Anfang, who lives in Coney\ Island, N.Y. \"He wasn\'t even heavy.\"\ \ Formaad, at 5 feet 8 and 166 pounds, was in excellent physical shape,\ medical records show. Friends said he swam dozens of laps every day\ and worked out with a personal trainer.\ \ Broward County Medical Examiner Joshua Perper ruled Formaad died of\ fecal peritonitis caused by perforation of the abdominal wall as a\ result of the surgery.\ \ Tiller said he took every possible precaution in light of Formaad\'s\ age, including performing the tummy tuck in a hospital rather than his\ office. He said that he also made sure Formaad spent a couple of days\ in the recovery center and that the patient was \"doing fine.\"\ \ Tiller said he has reservations about the medical examiner\'s finding,\ saying the \"stress\" of the surgery or intestinal problems might have\ caused the perforation.\ \ \"If I could see in the future, I shouldn\'t have done [Formmaad\'s\ operation), but every precaution was taken,\" Tiller said. \"The only\ way to guarantee nothing will happen is not to have a procedure done.\"\ \ Angela Umeda\ \ Age: 24\ \ Home: Lake Park\ \ Procedure: Breast implants\ \ Date of death: June 1, 1989\ \ With two young children to support, Umeda, 24, held jobs at a computer\ parts store and behind the deli counter of a chain grocery store. But\ she hoped to find work as a model and thought bigger breasts would\ help.\ \ A co-worker at the deli recommended Dr. Claude Fosdick, an ear, nose\ and throat specialist in West Palm Beach. A month before she planned\ to be married, the petite young woman decided to go ahead with the\ surgery. But she died in Fosdick\'s office of an overdose of lidocaine,\ the anesthetic she was given before the procedure, medical examiner\ records show.\ \ \"It\'s really been a nightmare. We all still think and dream about\ Angie,\" said her mother, Nellie Umeda, who lives in Jupiter. \"I love\ each and every one of my kids, but there was always something special\ between Angie and me.\"\ \ Umeda said she still cares for Angela\'s daughter, Alicia, now 17, who\ has a serious learning disability. \"Alicia won\'t sleep anywhere else\ but with me, because she\'s afraid the same thing that happened to her\ mother will happen to me. I really feel that losing her mom made her a\ lot worse. She is so withdrawn.\"\ \ State medical officials in a civil complaint filed in 1991 accused\ Fosdick of gross malpractice in Umeda\'s care. The state Board of\ Medicine in February 1992 suspended Fosdick\'s medical license until he\ could demonstrate to the board \"his ability to practice with skill and\ safety,\" according to legal records. Fosdick moved to Casa Grande,\ Ariz., where he now has a general medical practice.\ \ In February 1994, he signed an agreement with Arizona medical\ regulators. The agreement, which stems from Umeda\'s death, prohibits\ him from performing cosmetic surgery in Arizona.\ \ Fosdick\'s insurance company paid \$250,000 to settle a lawsuit by\ Umeda\'s family.\ \ Fosdick did not respond to phone calls or a letter seeking comment.\ \ Gwendolyn Rowland\ \ Age: 62\ \ Home: Melbourne\ \ Procedure: Face-lift and eyelids\ \ Date of death: Nov. 6, 1997\ \ Rowland and her husband of 42 years had just sold their Cocoa radio\ station and were looking forward to retirement, traveling and fishing\ on their boat. It seemed like a great time to have cosmetic surgery,\ so she paid \$8,000 for the operation at the Indian Harbour Beach\ office of Dr. David Packer.\ \ After the surgery, which lasted about nine hours, Rowland\'s husband,\ Robert, and their daughter arrived to pick her up. They sat in the\ waiting room, unaware that anything was seriously wrong until\ paramedics arrived and began working on Rowland, who had stopped\ breathing in the operating room.\ \ Paramedics took her to a hospital in Rockledge, where she was placed\ on life support. She died the next morning. The Brevard County Medical\ Examiner concluded Rowland died of cardiac arrhythmia, or an abnormal\ heartbeat, from hardening of the arteries. The medical examiner said\ the facial surgery was a \"significant condition\" contributing to her\ death.\ \ The Indian Harbour Beach Police Department is conducting a criminal\ investigation into the death, according to Detective Diane Davidson.\ She said police regulations prohibit her from discussing a pending\ case.\ \ Robert Rowland said his wife, who was 5 feet 2, weighed at least 160\ pounds and was taking medicine for high blood pressure, was not a good\ candidate for such a lengthy surgery.\ \ \"People have a perception that this is a cakewalk,\" Rowland said. \"But\ any time you go under anesthesia for more than six hours, it\'s serious\ stuff.\"\ \ Rowland, who said he settled a lawsuit against Packer for \$497,500\ earlier this year, was bitter for a long time over his wife\'s death.\ \"It was devastating to our family,\" he said. \"We started looking to\ each other for support, but it\'s been a very sad time.\"\ \ Packer had no comment, according to his attorney, Chuck Ingram.\ \ Peggy Sue Diehl\ \ Age: 58\ \ Home: Melbourne\ \ Procedure: Tummy tuck\ \ Date of death: April 2, 1998\ \ Diehl, a housewife and mother of five children, had been on a diet and\ lost about 20 pounds over the past year when she decided to get a\ tummy tuck. She went to Dr. David Packer in Indian Harbour Beach on\ March 31, 1998.\ \ Her husband, Phillip, took her home about 5:30 p.m. that day,\ according to medical examiner records. She slept on the couch all\ night.\ \ The next day, Diehl was very sore and lay on the couch most of the\ day, medical records state. About 6 p.m., her husband helped her\ upstairs so she could shower. But she collapsed and lost consciousness\ for about two minutes at the top of the stairs.\ \ Phillip Diehl, who slept in another room so he wouldn\'t bother his\ wife, put her to bed, then checked on her at midnight, and again at 3\ a.m. and 4 a.m. When he returned about 7 a.m. on April 2, he found her\ lifeless in bed.\ \ While the paramedics he called were en route, Diehl started CPR. His\ wife was pronounced dead at the scene. The Brevard County medical\ examiner concluded that Diehl died of a pulmonary embolism, or a blood\ clot in her lungs, from the cosmetic surgery. She also suffered from\ high blood pressure.\ \ Diehl said he could not discuss his wife\'s case in detail because a\ lawsuit is pending against Packer. It was the second death following\ cosmetic surgery in Packer\'s office within five months, records show.\ Packer\'s attorney, Chuck Ingram, said the surgeon would have no\ comment on either death.\ \ PLASTIC SURGERY: THE RISKS YOU TAKE - DESPITE INCREASE IN DEATHS,\ INJURIES, DOCTORS IN PRIVATE OFFICES ESCAPE STATE OVERSIGHT.\ Sun-Sentinel - Sunday, November 29, 1998\ Author: FRED SCHULTE AND JENNI BERGAL STAFF WRITERS\ William Formaad was a retired university professor who already looked\ far younger than his 71 years. He was embarrassed about having\ cosmetic surgery, so when he went to a Miami Beach surgeon for a tummy\ tuck, he told friends he was going to a spa to relax.\ \ Formaad died within a week of his operation, on March 10, 1997.\ \ Jeanette Mordica, a second-grade teacher, wanted to get rid of the\ bulges around her hips and thighs. She put aside her jitters about\ cosmetic surgery and went to a Hollywood medical office for a tummy\ tuck and liposuction.\ \ Mordica, 44, died the next day, on March 29, 1997.\ \ Two months later, when he wanted to get rid of the wrinkles on his\ face and eyelids, Ronald Jones, 50, went for a face-lift at the same\ office as Mordica. He thought his operation, for which he paid \$8,000,\ would be quick, safe and routine.\ \ Five hours after the surgery, the muscular former railroad worker lay\ comatose, swathed in bloody bandages, in a Hollywood hospital. He died\ three days later, on May 12, 1997.\ \ At least 34 people have died in Florida after plastic surgery since\ 1986. Thirteen of the deaths occurred in the past two years.\ \ A Sun-Sentinel investigation found that 1,100 injuries also took place\ under the care of Florida plastic surgeons since 1980.\ \ The injuries range in severity from painful skin burns to scarring\ that caused grotesque disfigurements, many of them permanent, the\ newspaper\'s computer analysis of Florida Department of Insurance\ records found.\ \ Most people who have cosmetic surgery heal promptly and are pleased,\ if not thrilled, with their new bodies, industry officials say. And\ tragic outcomes are relatively few when set against estimates that\ Florida physicians perform tens of thousands of cosmetic surgeries\ every year.\ \ But the state\'s top doctor, when told of the newspaper\'s findings,\ said the complications are too numerous and severe to ignore.\ \ \"I\'m very concerned,\" said Dr. James T. Howell, secretary of the\ Florida Department of Health. \"This is a very dangerous situation and\ there have to be major changes.\"\ \ The Sun-Sentinel\'s six-month investigation, using medical malpractice\ data, autopsy reports and other public records collected from agencies\ across Florida, is the first effort in the state to study deaths and\ complications from plastic surgery.\ \ The findings come as the cosmetic surgery industry is booming,\ especially in Florida.\ \ Floridians are going under the scalpel and the laser to have wrinkles\ smoothed, noses reshaped, fat sucked out and breasts enlarged at a\ furious pace. From 1992 through 1996, the number of cosmetic surgery\ procedures in the state grew 76 percent, according to the American\ Society of Plastic and Reconstructive Surgeons. Florida surgeons now\ perform 11 percent of the cosmetic procedures nationwide.\ \ It\'s a mostly cash business. Cosmetic surgery patients are paying\ thousands of dollars, most often out of pocket, for their new looks.\ An average face-lift, for instance, costs about \$4,600 in Florida, and\ because cosmetic surgery is elective, it is rarely covered by\ insurance.\ \ Patients often have several procedures done at once, which keeps them\ on the operating table for hours at a time and significantly increases\ the chances of complications or injuries.\ \ Under state law, any licensed doctor can perform cosmetic surgery,\ whether trained in the field or not.\ \ More and more of the operations are taking place not in hospitals,\ where regulations are strict, but in private offices over which state\ health officials impose few controls.\ \ Perhaps most troubling: No one is keeping close tabs on the industry.\ \ State health officials say they don\'t know how many people have died\ after cosmetic surgery. That\'s because they don\'t track those cases or\ require doctors to report them as a means of identifying those few\ doctors who repeatedly have problems.\ \ The lack of strict training and quality standards, the paucity of\ reports on complications, and cash-driven growth all add up to an\ industry with far too little state oversight, Howell said.\ \ He will urge the Florida Legislature to reassess laws that presuppose\ most types of cosmetic surgery pose relatively few risks and can be\ conducted safely in medical offices, he said.\ \ \"This really is something that is getting way out of control,\" Howell\ said. \"This is a money-driven area [of medicine), and it is getting\ worse and worse.\"\ \ Risk hard to assess\ \ For all its popularity and rapid growth in the past few years, the\ plastic surgery industry still can be confusing, even mysterious, to\ consumers.\ \ Even the terms can be hard to sort out. Plastic surgery encompasses\ both reconstructive and cosmetic surgery.\ \ Reconstructive surgery involves the correction of an abnormality\ caused by birth defects, disease or traumatic injury. It is generally\ covered by most health insurance policies, although coverage may vary.\ \ Cosmetic surgery entails reshaping a part of the body to improve a\ patient\'s appearance or self-esteem. Cosmetic surgery usually is not\ covered by health insurance because it is not considered medically\ essential.\ \ Just how much risk cosmetic surgery patients are taking is difficult\ to assess because state regulators collect no statistics on the number\ of complications and deaths.\ \ Doctors in the private practice of medicine are not required to report\ such deaths to the state. Nor are Florida\'s medical examiners, who\ investigate causes of unusual or suspicious deaths. State law simply\ does not require it.\ \ The Board of Medicine, which licenses doctors, also is left in the\ dark because it has no mechanism to study deaths occurring under the\ care of Florida physicians.\ \ \"Unless something\'s in the newspaper, we don\'t know about it,\" said\ board member Gary Winchester, a Tallahassee physician.\ \ No one is even sure exactly how many cosmetic procedures are being performed.\ \ Estimates of the number of procedures offered by national\ organizations that represent plastic surgeons vary widely, as do the\ types of operations they report and how they count them.\ \ The American Society of Plastic and Reconstructive Surgeons, with\ about 5,000 members, reported just under 700,000 cosmetic procedures\ nationwide during 1996, the latest year for which figures are\ available.\ \ Most common types of cosmetic surgery -- liposuction (or fat removal),\ breast augmentation, face-lifts, nose jobs, tummy tucks -- boomed\ between 1992 and 1997, according to the society. Women account for\ more than 80 percent of the cosmetic operations, but the number of men\ is increasing.\ \ Florida members of the society reported about 77,000 cosmetic\ procedures in 1996, with breast implants and liposuction near the top\ of the list. The number of breast implants and liposuctions has more\ than doubled since 1992. Overall, according to the society, Florida\ represents about 11 percent of the national total for cosmetic\ operations.\ \ By comparison, the 1,250-member American Society for Aesthetic Plastic\ Surgery reported almost 2.1 million procedures during 1997, but that\ organization included several additional categories, such as hair\ transplants and chemical face peels.\ \ Either count can be misleading, especially for liposuctions. A\ procedure to have fat removed from three areas of a patient\'s body\ during the same operation, for instance, is counted as three\ liposuctions.\ \ And like the state, neither trade group keeps statistics on the extent\ of complications, the number of deaths or the number of people\ dissatisfied with the outcome of cosmetic surgery.\ \ Problems can occur\ \ Mordica and Jones assumed the risks were minimal, as indeed they are\ for the great bulk of cosmetic surgery patients. But they died within\ seven weeks of each other after operations at the Hollywood plastic\ surgery office run by Dr. Richard Edison at 3109 Stirling Road.\ \ Edison, who operated on Jones, said neither death could have been\ prevented. \"Unfortunately, these are problems that occur with a small\ percentage of cases,\" he said.\ \ Mordica, the Miami-Dade schoolteacher, stood 5 feet tall and weighed\ 162 pounds. She hoped liposuction and a tummy tuck would prevail where\ diets had failed.\ \ Without telling her husband, who disapproved of cosmetic surgery,\ Mordica slipped off to the Hollywood medical office on March 28, 1997.\ Her \"anxiety level\" was \"high\" as the nursing staff readied her for\ the operation, according to the clinic\'s surgical notes.\ \ Mordica\'s operation was performed by Dr. Charles Messa III, a plastic\ surgeon who said he was a \"salaried physician\" at the office. Edison\ and Messa have since parted company.\ \ Everything seemed to have gone fine during Mordica\'s five-hour\ surgery. She spent the night recuperating in the office, as patients\ often do. She awoke about 7:30 a.m., drank a small glass of apple\ juice and chatted with a patient in the bed next to her, according to\ nursing notes.\ \ She called her daughter on her cell phone, then passed some time\ watching television. Less than half an hour later, however, Mordica\ complained of shortness of breath and dizziness and said her heart was\ racing. Soon after that, she went into cardiac arrest.\ \ The nurse on duty called 911 and paramedics took Mordica to the\ emergency room at Memorial Regional Hospital in Hollywood. She was\ pronounced dead at 9:15 a.m., according to Broward County Medical\ Examiner\'s Office autopsy records.\ \ \"It was unbelievable. You can\'t get over it, no way,\" said her\ husband, Bernard Mordica, who works for the Miami-Dade County water\ and sewer department. \"It was horrendous.\"\ \ The medical examiner ruled that Mordica\'s death resulted mainly from\ pulmonary thromboemboli, blood clots that form in the lungs. Medical\ authorities recognize thromboembolism as a complication of both\ liposuction and tummy tuck surgery.\ \ Messa said Mordica\'s death was \"extremely rare\" and a tragedy that\ could not have been prevented.\ \ \"This was very unfortunate,\" Messa said. \"This just goes to show that\ you try to keep safety the No. 1 thing, but even if you do that, you\ can\'t always account for everything.\"\ \ Edison said he and Messa practiced independently at Edison\'s Hollywood\ office and that he had \"nothing to do with\" Mordica\'s surgery.\ \ \"These are two different deaths. Each doctor had nothing to do with\ the care of the other,\" Edison said.\ \ The second tragedy came two months later at Edison\'s well-appointed\ office, where a picture window overlooks a tranquil lake in an office\ park.\ \ Just before 8 a.m. on May 12, 1997, Jones, a fitness freak who lived\ in Dania, got a ride to the office from his mother. Expecting the\ procedure to take five hours, he told her not to wait, that he would\ call her on his cell phone when it was finished.\ \ She began to panic after a flurry of phone calls from doctors at\ Hollywood Medical Center, where her son was taken when the operation\ suddenly went wrong after about five hours. One doctor said her son\ was on a respirator, fighting for his life. Another asked whether she\ would consider donating her only child\'s organs to the University of\ Miami transplant team.\ \ Jones never regained consciousness.\ \ \"This never should have happened,\" said his mother, Rose LaVallee, who\ lives in Dania. \"I expected to pick him up at the doctor\'s office\ after the surgery. Instead, I buried him.\"\ \ Broward medical examiner records show that Edison finished the\ face-lift just after noon and began working on Jones\' eyelids, the\ second part of the procedure. Records state the surgery was\ interrupted as Jones\' blood pressure fell precipitously about 1:30\ p.m.\ \ Broward Medical Examiner Perper ruled that Jones died of hypoxic brain\ injuries and coma complicated by bronchopneumonia. In essence, the\ flow of oxygen was cut off from his brain during the surgery for\ reasons that remain unclear.\ \ At the time of death, Jones had detectible levels of the\ anti-depressant drug Prozac in his body. \"It is unclear whether higher\ levels at the time of surgery played a role in the death,\" Perper\ wrote.\ \ Edison said that Jones died from cardiac complications resulting from\ use of the anti-depressant drug, which Jones had received from another\ doctor. Jones, Edison said, did not indicate his use of the\ anti-depressant drug on a medical questionaire he filled out before\ the surgery.\ \ \"Cardiac complications can occur with any operation,\" Edison said.\ \"I\'m a legitimate, board-certified plastic surgeon. I run a certified\ facility. The overwhelming majority of my patients get good results,\"\ he said. \"Any office can have unfortunate complications. We offer a\ good and safe service to the public.\"\ \ Fitness no protection\ \ The Sun-Sentinel tracked deaths and complications from plastic surgery\ using several sources: computerized Florida Department of Insurance\ medical malpractice claims data, lawsuits, autopsy findings, media\ reports and Florida Board of Medicine disciplinary-action records.\ \ Reporters reviewed more than 200 malpractice lawsuits in South Florida\ and searched files in medical examiners\' offices in five Florida\ counties to obtain autopsy reports and other records of cosmetic\ surgery deaths.\ \ The research found that deaths occurred in both men and women of all\ ages and from all economic classes. The causes ranged from\ complications of breast implant surgery in young women to face-lifts\ for the elderly. Six of the 13 people who died since 1997 were men,\ though men are far less likely than women to have plastic surgery.\ Five men who died were 50 years or older, records show.\ \ Formaad, the retired speech professor from Seton Hall University in\ New Jersey, was one.\ \ Formaad went to South Shore Hospital and Medical Center in Miami\ Beach, where Dr. J. Howell Tiller performed the operation on March 4,\ 1997. Formaad had paid Tiller \$3,500 for the procedure, which he\ billed to a credit card.\ \ Formaad spent the night at the hospital, then two nights at a recovery\ center near Tiller\'s home. Three days after the surgery, Formaad\ returned to his condominium, where he lived alone. Family members who\ phoned him said he was feeling poorly.\ \ \"It\'s unreal. My poor brother,\" Anfang said. \"He wasn\'t even heavy.\"\ \ Formaad, at 5 feet 8 and 166 pounds, was in excellent physical shape,\ medical records show. Friends said the 71-year-old swam 50 laps every\ morning and worked out with a personal trainer.\ \ Broward Medical Examiner Perper ruled that Formaad died from fecal\ peritonitis due to perforation of the abdominal wall as a result of\ the surgery.\ \ Tiller said he took every possible precaution in light of Formaad\'s\ age, including performing the tummy tuck in a hospital rather than his\ office. He said he also made sure Formaad that spent a couple of days\ in the \"recovery facility\" and that the patient was \"doing fine.\"\ \ Tiller said he has reservations about the medical examiner\'s finding;\ the \"stress\" of the surgery or intestinal problems, the doctor said,\ might have caused the perforation.\ \ \"If I could see in the future, I shouldn\'t have done [Formaad\'s\ operation), but every precaution was taken,\" Tiller said. \"The only\ way to guarantee nothing will happen is not to have a procedure done.\"\ \ Improper screening\ \ Autopsy reports of patients who died after cosmetic surgery usually\ don\'t pinpoint whether the deaths could have been prevented, though a\ few identify poor surgical techniques or errors with anesthesia as\ contributing to the patient\'s death.\ \ Some autopsy reports examined by the newspaper suggest surgeons did a\ questionable job of evaluating the patient\'s general health before the\ surgery.\ \ Certain factors -- age, weight, heart ailments or cigarette smoking,\ for instance -- are known to increase the risks of any surgery.\ \ Some surgeons said they laboriously explain these possible\ complications before surgery, both to achieve a bond of trust with the\ patient and to make sure relatives know what to expect during the\ patient\'s recovery stage.\ \ Family members \"should be on the lookout and be prepared for things to\ look for that may turn out to be problematic,\" Dr. Fredric Barr, a\ West Palm Beach plastic surgeon, testified in a deposition on behalf\ of the state in July.\ \ One possible complication is pulmonary thromboemboli, or blood clots\ that lodge in the lungs, which caused the deaths of three Floridians\ who died in their homes within a few days after cosmetic surgery,\ according to autopsy reports.\ \ Because these blood clots are a known risk of surgery, hospitals try\ to get patients up and around as quickly as possible after surgery.\ But doctors who operate in their offices often discharge the patient\ into the care of family members, who are not likely to have any\ medical training.\ \ A blood clot killed one of two women who died within five months of\ each other after seemingly routine cosmetic surgery in the Indian\ Harbour Beach office of plastic surgeon David Packer.\ \ Peggy Sue Diehl, 58, went to Packer\'s office on March 31, 1998, for a\ five-hour tummy tuck operation. She died two days later in the\ upstairs bedroom of her Melbourne home, records show.\ \ Diehl, a housewife with five children, died from a clot that lodged in\ her lungs because of the surgery, an autopsy found.\ \ Her husband, Phillip, who now lives in Mississippi, said he picked up\ his wife and drove her home to recuperate.\ \ Diehl, who slept in another room so as not to disturb his wife,\ checked on her at 3 a.m. and again an hour later on April 2, according\ to medical examiner\'s office records. At 7 a.m., when he went to check\ on her, she was dead in her bed.\ \ Five months before Diehl\'s death, another patient died just after\ cosmetic surgery in Packer\'s office.\ \ Gwendolyn Rowland, 62, of Melbourne, had a face-lift on Nov. 5, 1997.\ While resting in bed in Packer\'s office, she went into cardiac arrest\ and was taken to a local hospital and put on a breathing machine.\ \ She died the next day.\ \ Rowland died from cardiac arrythmia, or an abnormal heartbeat caused\ by heart disease and high blood pressure. The surgery contributed to\ her death, according to an autopsy report.\ \ Packer, through his attorney, Chuck Ingram, said he had no comment on\ the two deaths.\ \ Revealing records\ \ The Sun-Sentinel also analyzed 1,100 plastic-surgery malpractice\ claims filed with the state insurance department. The injured victims,\ whose names were removed from the records by state officials, span all\ age groups, though just over half were women in their late 30s.\ \ Injuries ranged from lacerations or temporary loss of sensation in\ some body part to permanent, serious damage. Permanent damage occurred\ in about 40 percent of the 810 cases for which the severity of the\ injury could be determined, records from 1986 to 1998 show. (Claims\ records from earlier years do not specify the extent of patient\ injuries.)\ \ The claims are cases in which companies insuring doctors expected they\ could be held liable for damages. The insurance companies assessed the\ severity of the patient\'s injuries, usually after reviewing the\ patient\'s medical records. Some plastic-surgery claims went to court;\ others were settled or dropped.\ \ The claims since 1986 have resulted in \$38.2 million in payments to\ compensate patients injured by plastic surgery.\ \ Among the injured: A 46-year-old Broward woman who underwent surgery\ to increase the size and lift of her breasts at the Florida Center for\ Cosmetic Surgery in Fort Lauderdale lost both nipples after breast\ tissue died. She required three additional operations and a breast\ reconstruction. Dr. Leonard Tachmes\' insurance company paid \$250,000\ to settle the case in February, records show.\ \ Tachmes said the woman had suffered damage after developing infections\ from previous surgery on her breasts before he ever operated on her.\ \ \"I tried to do the best I could do, to hit a home run, and it\ unfortunately didn\'t work as good as I wanted it to,\" Tachmes said. \"I\ consider myself an excellent surgeon.\"\ \ In another case, Dr. Daniel Callahan, then a plastic surgeon in St.\ Petersburg, allegedly took breast implants removed from an\ HIV-positive woman and inserted them into a 32-year-old woman,\ according to her claim. His insurance company settled the case in 1995\ with a payment of \$150,000.\ \ Callahan, who now practices in Mexico, denied the allegations at the\ time. He could not be reached for further comment.\ \ Unrestricted gold mine\ \ Under Florida law, any licensed physician can perform cosmetic\ surgery, whether trained in the field or not. That\'s because\ legislators in Florida, as in most states, have generally shied away\ from interfering with the private practice of medicine.\ \ Some doctors who have seen their incomes reduced as a result of\ managed care view cosmetic surgery as a gold mine. They have begun\ operating in their private offices or clinics, places state health\ inspectors have no authority to license or inspect.\ \ Hundreds of doctors in Florida -- from dermatologists to gynecologists\ to ear, nose and throat specialists, and even a few dentists -- now\ advertise their services as cosmetic surgeons.\ \ \"We have all sorts of doctors doing various things that probably they\ shouldn\'t be doing,\" said Palm Beach County Medical Society President\ Jana Rassmussen, a plastic surgeon who practices in West Palm Beach.\ \"It\'s very frustrating because they\'re trying to make ends meet\ economically and they\'re doing it at the jeopardy of patients.\"\ \ State officials are not sure how many cosmetic operations are\ performed in offices compared with those done in hospitals. But in a\ survey of its Florida members last year, the American Society of\ Plastic and Reconstructive Surgeons reported that 70 percent of the\ procedures are taking place outside a hospital.\ \ Many patients prefer it that way. Because insurance companies rarely\ pay for non-essential services such as cosmetic surgery, out-of-pocket\ costs can be substantial, often \$5,000 or more for a series of\ procedures in an outpatient setting. Hospitals, with their higher\ overhead, are even more costly.\ \ And many cosmetic surgeons offer discounts, as much as 50 percent off,\ if the patient opts for a second procedure. But the more complex the\ surgery, the longer it takes and the greater the risks of\ complications.\ \ Fatal blood clots in the lungs, for instance, occurred five times more\ often in people who had liposuction and a tummy tuck than in those who\ had liposuction alone, according to an article in the medical journal\ Plastic and Reconstructive Surgery.\ \ Citing the ongoing American Society of Plastic and Reconstructive\ Surgeons research, Miami plastic surgeon Edward Truppman said: \"So\ far, the common thread [in deaths) seems to be multiple procedures,\ operating time that is very protracted, eight, 10 hours.\"\ \ Twenty of the 34 deaths since 1986 found by the Sun-Sentinel followed\ surgery outside a hospital. And at least seven of the 13 patients who\ died in the past two years underwent more than one procedure,\ according to medical examiners\' records.\ \ Boynton Beach plastic surgeon Mark Schreiber, who was disciplined by\ state medical officials in October after a patient died following\ several cosmetic operations that took 10 hours, suggested that\ surgeons are influenced by the competitive market and patient\ convenience.\ \ \"There\'s a lot of pressure on people to daisy-chain and put all of\ these procedures together,\" Schreiber testified at his October hearing\ before the Board of Medicine in Tampa.\ \ Department of Health Secretary Howell said the state has a duty to set\ standards that will protect the public. The board is considering\ limiting the duration of office surgeries as well as the amount of fat\ removed during liposuction.\ \ \"We are seeing risks being taken and we don\'t consider them\ appropriate,\" Howell said. \"I never in my wildest dreams would have\ thought people would be staying in the doctor\'s office for 24 hours.\"\ \ But seemingly routine plastic surgery in hospitals also can go wrong.\ \ Scott Michael Rudd, a 21-year-old Florida State University senior who\ hoped to enter law school after graduation, died in August 1997 after\ plastic surgery to improve the appearance of his jaw.\ \ Rudd, a Coral Springs resident and former high school football star\ and wrestler, died after going into cardiac arrest during the\ procedure at Westside Regional Medical Center in Plantation.\ \ Still, critics worry that private offices may not stock adequate\ emergency equipment, verify the training levels of staff or impose the\ same medical-quality protocols hospitals or outpatient surgery centers\ must meet under state law.\ \ Many hospitals would, for instance, require anyone over age 50 to have\ precautionary heart tests before surgery with a general anesthetic,\ said Dr. Gustavo Leon, a Miami surgeon and member of the Florida Board\ of Medicine.\ \ Ten of the 13 Florida plastic surgery deaths during the last two years\ involved patients 50 or older, medical examiners\' records show.\ \ Hospitals also monitor the performance of surgeons over time and\ require \"peer reviews\" that may restrict or remove physicians found\ incompetent.\ \ Doctors\' offices, however, are not inspected, or even counted, by the\ state. Thomas K. Hannah, a senior state health investigator, estimated\ the number of offices at \"more than 10 and less than 25,000.\"\ \ Coral Springs plastic surgeon H. Michael Bass summed up his fears this way:\ \ \"Doctors are operating in the privacy of their offices, hidden from\ the scrutiny of other physicians and from regulatory bodies,\" Bass\ said. \"Their facilities may be sorely substandard, and they may be\ putting their patients at serious risk.\"\ \ TRAINING FOR LASER SURGERY CAN BE LAX\ Sun-Sentinel - Monday, November 30, 1998\ Author: FRED SCHULTE and JENNI BERGAL Staff Writers\ Anne McGan, who had suffered skin damage from long exposure to the\ sun, hoped that laser treatments by Dr. Madhudsudan Parikh would\ smooth out the wrinkles on her face.\ \ But she ended up severely disfigured when the laser burned her instead\ of restoring youthful looks, state health agency records state.\ \ McGan, 59, was one of six injured patients cited in a Florida\ Department of Health emergency order barring Parikh, an Ormond Beach\ plastic surgeon, from using a laser for cosmetic surgery.\ \ Parikh caused \"deep, permanent, disfiguring third-degree burns and\ pain without recognizing his responsibility for their crippling\ injuries,\" according to the March 1998 order.\ \ The state complaint also cited Parikh for failing to report the laser\ injuries to the state\'s Bureau of Radiation Control in Tallahassee.\ State law requires these reports, though many doctors are not aware of\ the requirement, said bureau official James Fetch.\ \ Parikh had no comment. But his attorney, Paul Lambert, said the laser\ burns were not caused by the surgeon, but by a problem with the laser\ itself. He said Parikh and his insurance company are suing the\ device\'s manufacturer and expect the state to drop its case.\ \ \"In the end, I feel confident those charges against him are going to\ be dismissed,\" Lambert said.\ \ McGan, who settled a lawsuit against Parikh for an undisclosed sum,\ also blames the state for her predicament.\ \ \"The state has no controls over who is performing laser surgery,\" said\ McGan, who lives in Daytona Beach. \"Even the doctor who removed my\ wisdom tooth is doing it. The state just ignores all this. I think\ it\'s awful.\"\ \ Lasers, highly concentrated pinpoint beams of light, are used to get\ rid of scars, wrinkles and other skin defects. The light removes\ layers of skin by vaporizing them, and in the right hands, experts\ say, lasers can be a relatively painless way to accomplish wrinkle\ removal.\ \ In 1996, doctors across the country performed 138,891 laser\ procedures, according to the American Academy of Cosmetic Surgery. The\ Chicago-based group includes various types of doctors who perform all\ types of cosmetic surgery, from dermatologists to dentists.\ \ How often lasers cause injury is not known, although one article in\ the Aesthetic Surgery Journal in July 1997 found \"undesirable\ outcomes\" occurred mainly in the early stages of a doctor\'s\ experience. A study of 1,925 patients found that 537, or 28 percent,\ perceived an adverse outcome, according to the report co-authored by\ Dr. Jason N. Pozner, a surgeon at the Florida Center for Cosmetic\ Surgery in Fort Lauderdale.\ \ Some doctors say too many people are using the lasers after taking\ quickie courses. Dr. Steven Rosenberg, a past president of the Florida\ Society of Dermatology who practices in West Palm Beach, is one\ critic.\ \ He said he often receives letters from companies that manufacture\ lasers inviting him to take one-day courses in the technique. Some\ stress the big money he can make offering this service to his\ patients.\ \ Rosenberg isn\'t buying, and doesn\'t use lasers in his practice. He\ considers the solicitations junk mail and quickly tosses them away.\ \ \"The only people who should be doing [laser surgery) are people with\ the experience and training,\" Rosenberg said.\ \ The American Society for Laser Medicine and Surgery, a trade group\ based in Wisconsin, said doctors should receive a minimum of eight to\ 10 hours for starters, then receive further training with an\ experienced laser operator to allow the student to observe a number of\ different procedures being done on patients.\ \ But some doctors who don\'t use lasers say many training sessions they\ are invited to attend fall short of that standard.\ \ \"They may fire a laser at a couple of grapefruits,\" said Dr. Mark\ Unis, a Fort Lauderdale dermatologist and past vice president of the\ state dermatology society. \"And then they start to do it on patients.\"\ \ PATIENT BRIEFING OFTEN SKETCHY\ Sun-Sentinel - Monday, November 30, 1998\ Author: FRED SCHULTE and JENNI BERGAL Staff Writers\ Patients unhappy with their cosmetic surgery and looking for someone\ to blame should first look in the mirror, says Orlando attorney John\ Bocchino.\ \ \"I have always felt that cosmetic surgery patients generally have\ expectations that are problematic and will lean them toward filing a\ lawsuit when things don\'t work out,\" said Bocchino, who has spent\ years defending surgeons against medical malpractice.\ \ \"If they have any complication, even the most minor problem,\" he said,\ \"they feel the doctor screwed up.\"\ \ Not surprising, from a lawyer who defends doctors. Nor is it\ surprising that many doctors agree with him. Too often, the doctors\ say, patients just don\'t listen to their warnings about limitations\ and possible risks of cosmetic surgery.\ \ \"Patients frequently hear what they want to hear,\" said Dr. Edward\ Truppman, an Aventura plastic surgeon who is president of the Florida\ Society of Plastic and Reconstructive Surgeons. \"Sometimes you repeat\ things three times and they still don\'t hear it.\"\ \ Circuit court clerks in Florida don\'t maintain medical malpractice\ lawsuits by specialty, so it is not possible to determine from public\ records whether or why plastic surgeons draw more than their share of\ lawsuits.\ \ But many doctors do expect to be sued. One Washington state company,\ Mirror Image, is capitalizing on that by selling computer software\ intended to protect plastic surgeons from lawsuits.\ \ The program requires patients to acknowledge their understanding of\ risks and complications to \"graduate\" from a 20-minute presentation,\ which includes quizzes on the fine points of having breast implants or\ other cosmetic surgery.\ \ \"An amazing thing happens when patients decide to take legal action\ against you. They develop a strange form of amnesia,\" reads a\ marketing brochure for the \"Confirm Informed Consent Documentation\ System.\"\ \ Many patients think, erroneously, that cosmetic surgery can absolve\ the patient of the need to take proper care of the body, attorney\ Bocchino said. \"We\'ve graduated into a society who wants to look\ better. They don\'t want to diet or exercise. They want to get\ liposuction and eat like pigs and have nice shapely butts,\" he said.\ \ Bocchino suggested that such patients who approach cosmetic surgery on\ a whim may be tempting fate. \"The bottom line is you\'re fooling around\ with what God gave you. You shouldn\'t go under the knife unless you\ absolutely have to.\"\ \ Some patients acknowledge they should have asked more questions before\ going under the knife, about the amount of pain after surgery, for\ instance. But many still think that surgeons tend to downplay risks.\ \ Anita Hunt, of Oakland Park, said she relied on the surgeon\'s glib\ advertising, ritzy office and confident demeanor during a quick chat\ before having cosmetic surgery in Fort Lauderdale last year.\ \ \"They paint a beautiful picture that you\'ll be feeling fine and back\ to your old self in two weeks,\" said Hunt.\"They need to be more\ honest.\"\ \ Consent forms that patients sign before surgery, and literature\ explaining the procedures, vary widely in detail. Some pamphlets\ recite information about complication rates only in the vaguest of\ terms, which offer patients little guidance. Many brochures on\ liposuction, for instance, list a number of possible complications but\ give no indication of their likelihood.\ \ Dr. Fredric Barr, a West Palm Beach plastic surgeon and consultant to\ the state Board of Medicine, said he sits down and laboriously\ explains the possible complications during consultations with the\ patient and family members to achieve a bond of trust with the patient\ before surgery.\ \ \"The relationship you start with the patient is what you end up with.\ We like to say you\'re married to your patient,\" Barr testified in a\ deposition on behalf of the state in July.\ \ Dr. Lawrence Korpeck, a Boca Raton plastic surgeon, agrees that\ doctors should never push patients into booking surgery too quickly or\ on a whim.\ \ \"The happiest patients are the ones who are informed,\" Korpeck said.\ \"You need to sit down and tell them what they have to go through. Once\ they are informed and know what to expect, they\'re a lot happier.\"\ \ Some doctors also don\'t reveal much to their patients about their\ qualifications to perform certain types of surgery.\ \ Reviewing lawsuits in South Florida, the Sun-Sentinel discovered four\ cosmetic surgeons who testified that they had performed procedures on\ patients for which they lacked proper training or had little or no\ experience.\ \ For instance, Dr. Jose A. Jurado, who owned a cosmetic surgery center\ in Hialeah, performed a breast surgery in 1987 on a woman even though\ he had never done the procedure in 13 years of practicing in South\ Florida, according to a 1990 state medical board report. The woman\ required extensive reconstructive surgery as a result, according to\ the report. Jurado, who has since voluntarily given up his medical\ license, did not respond to requests for comment.\ \ Ray McEachern, who heads the Association for Responsible Medicine, a\ grassroots consumer organization based in Tampa, is pressing for state\ laws to require doctors to more thoroughly discuss medical treatments\ with their patients.\ \ \"Informed consent should be a process that is laid out in law,\" he\ said. \"Right now, it\'s based on what the medical community decides to\ tell the patient.\"\ \ LACK OF REGULATIONS HEIGHTENS SURGICAL RISKS - COSMETIC OFFICE\ PROCEDURES LARGELY GO UNREGULATED BECAUSE THE STATE HAS NO WAY TO\ TRACK THEM.\ Sun-Sentinel - Monday, November 30, 1998\ Author: Fred Schulte and Jenni Bergal\ Leon Doyan seemed to many patients to be the ideal plastic surgeon.\ \ He was steely-eyed and self-confident, several patients said. He\ flattered women who visited his Broward County offices, promising some\ he would make them into perfect \"10\'s,\" like movie actress Bo Derek.\ \ But some clients came to regret trusting Doyan with their bodies, or\ their money.\ \ Between 1993 and 1997, eight patients filed malpractice lawsuits\ accusing Doyan of badly scarring them during surgery in his office.\ \ One woman said he left a gaping hole in her belly.\ \ A second woman who filed a malpractice suit against Doyan said he\ talked her into having extra surgery after she was tranquilized and\ about to be wheeled into the office operating room. Doyan sold her on\ an experimental procedure to enlarge her breasts, which he agreed to\ throw in for \$500 in cash, according to court testimony.\ \ Another woman filed a complaint with state investigators alleging that\ Doyan fondled her breasts and attempted oral sex on her during a visit\ to his office.\ \ After logging such complaints over a period of more than three years,\ the Florida Board of Medicine revoked Doyan\'s medical license in\ November 1995.\ \ Doyan appealed and remained in practice until December 1996, when the\ appeals court upheld the revocation of his license.\ \ Doyan, 58, has dropped out of sight.\ \ His ex-wife and former office manager, Lucy Doyan, still works at the\ Cosmetic Surgery Institute of Florida on East Oakland Park Boulevard\ in Fort Lauderdale, where Doyan last operated before his license was\ revoked. He previously had an office in Coral Springs.\ \ \"I don\'t have any idea where you can find him,\" said Lucy Doyan. \"He\'s\ not involved with anything involving this facility now.\"\ \ Disciplinary action lags\ \ Florida has grown swiftly into one of the nation\'s top cosmetic\ surgery markets. At least 470 Florida plastic surgeons perform more\ than 70,000 operations in the state every year.\ \ Many doctors whose specialties are in fields other than cosmetic\ surgery -- the state doesn\'t know just how many -- have joined them in\ performing cosmetic operations.\ \ The number of the common types of cosmetic surgery -- liposuctions (to\ suck fat out of the body), breast enhancements and tummy tucks -- have\ more than doubled in the last five years, according to industry\ groups.\ \ With the unbridled growth has come a sharp rise in patient\ complications and deaths. Since 1986, at least 34 people have died\ following plastic surgery around the state, medical examiner and\ insurance department records show. Thirteen people died between\ January 1997 and September of this year.\ \ Yet efforts to study why complications are occurring in seemingly\ routine cosmetic surgery -- and to impose training standards and to\ discipline surgeons responsible for substandard care -- are lagging\ far behind the industry\'s growth, a Sun-Sentinel investigation found.\ \ Among the findings:\ \ * Dozens of Florida doctors have continued to perform plastic surgery\ for years despite state sanctions against their medical licenses,\ multiple insurance claims for malpractice or repeated lawsuits\ alleging they injured patients through negligent care.\ \ * Most cosmetic surgeons operate from private medical offices outside\ the watch of state health inspectors, and where no standards for\ training or competence are imposed. Private doctors, unlike hospitals,\ are not required to report complications or patient deaths to the\ state for review.\ \ * New cosmetic surgery techniques -- \"large-volume\" liposuction that\ removes major quantities of fat, and growing numbers of multiple\ procedures that can take eight hours or more -- are increasingly being\ used in doctors\' offices even though state health officials have not\ evaluated their safety.\ \ Growing alarm over the safety of office-based surgery comes as\ Florida\'s Department of Health already is trying to dig out from under\ lengthy backlogs in disciplinary cases against all types of doctors,\ which can drag on for years without resolution.\ \ \"We\'ve got to have a damn better system to get on top of this,\" said\ Dr. James T. Howell, secretary of the Florida Department of Health.\ \"I\'m seeing cases come across my desk that are six years old.\"\ \ Untracked operations\ \ Florida officials have a tough time policing the cosmetic surgery\ industry because no single agency in state government tracks deaths,\ complications, or just poor performance by office-based physicians.\ \ Cosmetic surgeons who operate out of their offices -- industry\ estimates show that 70 percent of cosmetic surgeons do so -- are not\ obligated to report complications to the state\'s Agency for Health\ Care Administration in Tallahassee for review.\ \ By contrast, hospitals must report life-threatening complications both\ to alert the state to unusual medical injuries and errors and to help\ assess whether physicians should be disciplined.\ \ Florida\'s Board of Medicine, which licenses doctors, has drafted\ legislation to compel doctors to report office complications and\ deaths, but the proposal faces opposition from the Florida Medical\ Association, which lobbies for the state\'s doctors. The medical\ association fears such a regulation would be burdensome and not\ improve the quality of medical care.\ \ But Dr. Donato A. Viggiano, a plastic surgeon in Port St. Lucie,\ argues that cosmetic office surgery is \"essentially unregulated\"\ because the state has no means to track the types of procedures being\ done and the complication rates for them.\ \ Viggiano expects the situation to worsen. More doctors with\ questionable training are likely to take up cosmetic surgery to boost\ their incomes, which \"will increase the use of the office surgery\ loophole to the detriment of patient safety,\" Viggiano wrote in a 1997\ letter to state authorities.\ \ Meanwhile, state health officials in Tallahassee don\'t take advantage\ of physician-performance data already available to them, such as\ Florida Department of Insurance malpractice claims.\ \ State law requires companies selling malpractice insurance to\ physicians to report all claims, including the name and specialty of\ the physician, type of medical procedure, extent of injuries and the\ amount of money paid to compensate the patient. That information is\ sent to the Department of Insurance, which keeps statistical\ information, and the Agency for Health Care Administration, which is\ supposed to track problem doctors.\ \ Julie Weeks, a health care agency manager, said the information is\ entered into a computer, which has a system to trigger an alert each\ time a doctor\'s insurance company has paid three malpractice claims of\ \$25,000 or more within a five-year period. Those cases are then\ reviewed by state health officials, she said.\ \ The Sun-Sentinel obtained these data on computer disks and analyzed\ the malpractice claims histories of 402 Florida plastic surgeons who\ were the targets of claims between January 1986 and April 1998.\ (Claims before 1986 were less detailed.) The claims don\'t include\ doctors who carry no insurance.\ \ The newspaper\'s review showed that 61 of the surgeons were the subject\ of four or more claims during this period. Three plastic surgeons had\ more than a dozen malpractice claims, placing them among the most\ complaint-prone doctors in the state, records show.\ \ Overall, four of the state\'s 20 doctors with the most malpractice\ claims were plastic surgeons, even though plastic surgery is among the\ smallest of 31 medical specialties.\ \ When measured against other medical specialties in Florida, plastic\ surgeons had the fourth-highest rate of malpractice claims, according\ to state health data. Thoracic surgeons are the highest, followed by\ orthopedic surgeons and neurologists.\ \ Other methods of reporting patient injuries to the state don\'t always\ trigger an investigation of the doctor involved, either.\ \ State law requires attorneys for plaintiffs to advise the state when\ they are contemplating a medical malpractice lawsuit against a Florida\ physician. Once the state gets the notice, it requests that patients\ sign an authorization form releasing their medical records.\ \ But state health officials said many patients decline to release that\ information, one of several reasons an investigation can stall. The\ agency received 3,263 pre-lawsuit notices last fiscal year, for\ example, but opened only 562 investigations, state computer records\ show. None concluded with disciplinary action by the Board of\ Medicine.\ \ Even when the state does launch an investigation, the case is likely\ to take years to resolve because of a lengthy system of hearings and\ appeals to which physicians are entitled.\ \ In an April 1996 report, state auditors found that it took from 19 to\ 40 months on average to discipline a Florida doctor. Cases can take\ even longer when the doctor contests the state\'s charges through a\ series of administrative hearings.\ \ The Florida Legislature in 1997 ordered health officials to do better,\ approving a law that requires the state to move consumer complaints at\ least to a hearing within six months.\ \ The mandate comes as complaints against all types of doctors are on\ the rise. State officials opened 900 such cases in the last four\ months of 1997 alone, according to state records.\ \ For patients with complaints, the process often means years of waiting.\ \ \"The system is failing consumers,\" said W.M. Chanfrau, a Daytona Beach\ lawyer who represents eight patients who have sued a local plastic\ surgeon. \"There is no incentive for the medical profession to clean up\ its act.\"\ \ Other lawyers agree, and worry that as plastic surgery continues to\ grow in popularity, the problems will worsen.\ \ \"We see everything -- tummy tucks gone bad, breasts deformed after\ implant surgery. It\'s unbelievable,\" said Robert Spector, a Fort\ Lauderdale attorney who specializes in medical malpractice.\ \ No special training\ \ The state effort to discipline cosmetic surgeons is further\ complicated by the fact that, under state law, any licensed medical\ doctor can perform cosmetic surgery -- whether trained in the\ specialty or not.\ \ Doyan offers an example. He trained as a general surgeon and practiced\ in New York and Massachusetts before receiving a Florida medical\ license in 1978. Though he had \"nominal training and very little\ experience\" in cosmetic surgery, he started performing it in South\ Florida in 1989, according to a judge\'s written order.\ \ He advertised \"the most advanced cosmetic surgical procedures and\ techniques,\" including a controversial process of injecting fat into\ breasts to enlarge them.\ \ Few patients possess the medical knowledge to judge the merits of\ these sorts of claims, or other claims of training -- such as\ \"board-certified.\"\ \ State law prohibits doctors from suggesting they possess superior\ training and skills -- or from saying they are \"board-certified\" in\ plastic surgery unless they have passed rigorous written and oral\ examinations given by the American Board of Plastic Surgery in\ Philadelphia or the American Board of Facial Plastic and\ Reconstructive Surgery in Alexandria, Va. These are the only plastic\ surgery boards recognized by the state.\ \ But there is no requirement that a doctor be board-certified and none\ is likely given the reluctance of state regulators to impose such\ controls on the private practice of medicine. That leaves doctors in\ Florida free to obtain cosmetic surgery training anywhere -- whether\ it be from a university residency program that requires years of study\ to a quick course advertised on the Internet.\ \ Many such quick courses exist. For instance, a group called the\ American Board of Aesthetic Medicine and Surgery Inc. offered in 1996\ to teach the fine points of doing face-lifts for a \$2,500 fee.\ \ The attendees were promised their own cadaver head to practice on\ during the two-day, 20-hour training session at a hospital in suburban\ Chicago.\ \ Upon completing the course, the graduate received credit toward\ certification by the American Board of Aesthetic Medicine and Surgery,\ whose president is Chicago doctor Daniel Saviano.\ \ Saviano\'s Website says his board gives doctors a chance to gain\ proficiency in cosmetic surgery regardless of their previous\ experience. Saviano did not respond to numerous requests for comment.\ \ While no plastic surgery training is required under Florida law, it\ can become an issue in a medical malpractice lawsuit.\ \ Consider the case of Dr. Douglas Dedo, a Palm Beach Gardens\ board-certified facial plastic surgeon, whose office wall bore a\ certificate from the American Society of Cosmetic Breast Surgery.\ \ A woman won a \$250,000 jury verdict against Dedo in 1992 for\ malpractice, claiming he botched her breast implant surgery. Testimony\ in the trial showed that Dedo\'s training in breast enlargement at the\ time consisted mainly of taking the breast surgery society\'s five-day\ seminar in the Bahamas.\ \ The American Society of Cosmetic Breast Surgery\'s phone number rings\ in the Newport Beach, Calif., office of plastic surgeon William\ Morgan. Reached at the office, Morgan said he was busy seeing patients\ and would call a reporter back. Subsequent calls and a letter\ requesting comment brought no response.\ \ Janie Cordray, research manager for the Medical Board of California,\ said her group had no knowledge of the society. She said it is\ impossible to keep track of such organizations, which are scattered\ across the country.\ \ Oklahoma\'s Board of Medical Licensure in 1990, however, refused to\ permit an Oklahoma cosmetic surgeon to declare himself\ \"board-certified\" based upon training received from the American\ Society of Cosmetic Breast Surgery. That decision was upheld by the\ state\'s highest court in 1993.\ \ Dedo said that the Newport Beach board is legitimate and that he was\ adequately trained previously to perform the breast enlargement. He\ said he no longer performs breast surgery.\ \ Dedo said surgeons need not attend formal medical school residency\ programs to learn new cosmetic surgery techniques. He said that in\ 1983 he taught himself liposuction by practicing on a pig he bought in\ Loxahatchee in rural Palm Beach County.\ \ Dedo, a past president of the Palm Beach County Medical Society, said\ most surgeons are perfectly competent to perform procedures such as\ face-lifts, liposuction and breast enlargement.\ \ \"Plastic surgery is purely a technique of handling tissue. It\'s used\ by every specialty,\" Dedo said. \"Anyone can do it, if you know anatomy\ and basic surgical principles.\"\ \ Some plastic surgeons argue that physicians who lack adequate training\ should be forbidden from holding themselves out as specialists in the\ field.\ \ Most outspoken are members of the American Society of Plastic and\ Reconstructive Surgeons, which boasts 5,000 members nationwide, and\ about 400 in Florida. Its members have passed the written and oral\ examinations given by the American Board of Plastic Surgery.\ \ The society\'s members also must have five years in surgical training\ after medical school, including at least two in plastic surgery.\ \ Even society officials acknowledge that many patients have a tough\ time sorting out the meaning of these terms.\ \ \"This is confusing for the public,\" said Dr. Russel Palmer, president\ of the plastic surgery society\'s Broward County chapter. \"A lot of\ people want to call themselves \'board-certified\' plastic surgeons and\ so they create their own board. It\'s troubling.\"\ \ Poor results and malpractice, including serious complications and even\ deaths, tend to occur at the hands of cosmetic surgeons who lack\ extensive formal training, they argue.\ \ \"There are calamities in cosmetic surgery,\"said Dr. Peter Simon,\ former chief of plastic surgery at North Ridge Medical Center in Fort\ Lauderdale. \"Anybody who is a medical doctor can do anything he wants\ and they just shouldn\'t be allowed to do that.\"\ \ The Sun-Sentinel examination of state records found more than a dozen\ Florida doctors, each with four or more medical malpractice claims or\ disciplinary sanctions, who either were not board certified as plastic\ surgeons or lacked demonstrated formal training in plastic surgery.\ \ Dr. Arturo Calvo, formerly of Clearwater, who was not board-certified,\ settled seven medical malpractice claims from 1993 through 1996\ totaling \$865,000, insurance records show.\ \ He also was fined \$3,000 by the Florida Board of Medicine in September\ 1993 after the state alleged that he left a wooden splint inside a\ woman who underwent a nose job.\ \ In February 1998, the state filed another civil action against Calvo\ alleging his negligence contributed to a 57-year-old woman\'s serious\ infection following breast surgery. That case is pending. Calvo\'s\ attorney, John Bocchino of Orlando, said Calvo denies any wrongdoing.\ The surgeon has not renewed his Florida medical license because of\ poor health and has moved to Central America, Bocchino said.\ \ But certification by a recognized board does not necessarily guarantee\ good results for the patient, insurance records show.\ \ The newspaper study found that 80 percent of injury claims were\ attributed to plastic surgeons who were board-certified and could\ document extensive training.\ \ Nor do board-certified plastic surgeons always escape medical\ malpractice lawsuits, court records show.\ \ Dr. Jerry Lingle, medical director of the American Institute of\ Cosmetic Surgery in Fort Lauderdale, is a board-certified plastic\ surgeon with a medical career spanning more than two decades. Yet\ Lingle has faced nine medical malpractice lawsuits filed against him\ since 1996 in Broward Circuit Court.\ \ The state medical board suspended Lingle\'s license in May after\ concluding he had been negligent in caring for three patients,\ including a woman who collapsed on the sidewalk outside his clinic and\ suffered seizures from an overdose of anesthetic. She spent five days\ in a hospital intensive care unit recuperating from liposuction.\ \ Under a deal he signed with the state\'s medical licensing agency,\ Lingle was able to return to practice this month. Lingle would not\ comment.\ \ Pushing the limit\ \ Many members of the Florida Board of Medicine think the types of\ cosmetic procedures taking place in private medical offices are\ getting riskier. They worry about eight- or 10-hour sessions that\ combine liposuction of several body sites with face-lifts or tummy\ tucks. That\'s as long, or longer, than it takes to do a heart or\ kidney transplant in a hospital.\ \ Another worrisome development: so-called \"large-volume\" liposuction in\ which as much as 10 pounds or more of fat is removed from the body.\ The procedures require extensive use of anesthesia and can result in\ anemia or other complications.\ \ Recognizing that state regulators have no power to inspect surgeons\'\ offices, the state board is studying whether to limit the amount of\ fat that can be removed during an office procedure. In the meantime,\ the state board is arguing that large-volume liposuction cannot be\ performed safely outside of a hospital.\ \ In August, the board filed a civil complaint against plastic surgeon\ Jeffrey Hamm, who performed a large-volume liposuction procedure to\ remove fat and tissue from the thighs, buttocks and abdomen of a\ Sunrise woman in his Hollywood office in February 1997.\ \ The woman, Dara Krugman, spent two days in a Plantation hospital and\ required transfusions to replenish blood lost during the surgery,\ according to the state complaint.\ \ The state accused Hamm of practicing medicine \"below the standard of\ care\" by failing to order adequate blood tests before surgery and by\ not doing the procedure in a hospital to \"insure patient safety.\"\ \ Hamm said he would have no comment on the state complaint. \"This\ hasn\'t been resolved,\" he said.\ \ The use of other controversial techniques usually doesn\'t lead to\ disciplinary action -- unless disaster strikes.\ \ Miami cosmetic surgeon Ricardo Samitier, for instance, built a\ lucrative practice in the early 1990s by using fat taken by\ liposuction from other parts of men\'s bodies to thicken their penises.\ He charged them more than \$1,000, court records show. Samitier once\ appeared on Howard Stern\'s show to discuss his procedure.\ \ The state suspended Samitier\'s license in 1992, following the death of\ Latin singer Claudio Martell, 47, who bled to death after penile\ enlargement and abdominal liposuction in the doctor\'s office. The\ state revoked Samitier\'s license in 1994.\ \ Yet dozens of Florida doctors continue to do fat injections, often\ taking fat removed from female patients by liposuction and injecting\ it into their breasts to enlarge them.\ \ While state officials have argued in civil actions that the injections\ can cause serious infection and rock-like lumps in the breast, they\ have not ordered physicians to halt the practice.\ \ The buck stops here\ \ Department of Health Secretary Howell says he hopes his agency will\ meet the challenge of setting new, tough standards to enhance the\ safety of cosmetic surgery.\ \ As a first step, the board of medicine has held three public hearings\ across the state to solicit opinions, mainly from doctors, over what\ steps to take. Under discussion: Requiring reporting of complications,\ accrediting office surgery units, and demanding physicians who perform\ office surgery to demonstrate that they are competent. The board could\ act by the end of the year.\ \ His agency also is cracking down on doctors, Howell said. He cites\ three emergency orders he has signed this year restricting the\ licenses of Florida plastic surgeons. Howell said the state\'s\ medical-licensing board is making progress toward speeding up\ disciplinary hearings and is writing new standards requiring better\ training and medical-quality controls for office surgery.\ \ Yet many plastic surgeons worry that the board already has been too\ lenient in imposing discipline in recent cases, such as the one\ involving Lingle and another against Boynton Beach plastic surgeon\ Mark Schreiber.\ \ The board in October fined Schreiber \$5,000, and placed him on\ probation for one year following the anesthesia overdose death of a\ 51-year-old Lantana man who had liposuction and a penile implant in\ Schreiber\'s office. Daniel Parish died in January after more than nine\ hours of cosmetic surgery.\ \ Howell acknowledges that the board of medicine is the target of\ criticism both from within the medical profession and from the public.\ But he insists that the board is cracking down.\ \ \"The board needs to get incompetent people out of business,\" Howell\ said. \"They reflect on the entire medical profession. The buck stops\ at the board.\"\ \ \"Obviously,\" he said, \"the system needs repair.\"\ \ Too late for some\ \ Some of Doyan\'s patients wish repairs to the system had come sooner.\ \ \"I\'m a mess from this. I had to have 18 reconstructive surgeries, if\ that tells you anything,\" said Ellen Ross, a Davie beauty shop\ operator who had liposuction and an experimental breast enlargement\ performed by Doyan. \"I\'m still pretty mangled.\"\ \ Ross said she also was angry that she got talked into the breast\ procedure after she was given a tranquilizer, according to arguments\ her lawyer made to a judge, who later awarded Ross a \$1.8 million\ judgment.\ \ Some Doyan patients also wish they had spent more time checking into\ Doyan\'s background and questioning his judgment and surgical\ techniques.\ \ Virginia Goodrich, for one.\ \ Goodrich, now 54, left Doyan\'s office after a tummy tuck and breast\ enlargement, using fat taken from her body. She quickly fell victim to\ an infection that took months to heal. Her surgical scars were so bad,\ she said, that her daughter could put her fist inside the wound left\ in her abdomen.\ \ Early one morning, she screamed for her daughter to come help her.\ \"All the stitches were popping out and black and green smelly bile was\ oozing out of my stomach,\" Goodrich said. \"I was hysterical. I\ couldn\'t walk. I couldn\'t eat. I had a 103-degree fever.\" She went\ back to see Doyan for a series of treatments that she said didn\'t cure\ her.\ \ Goodrich, a waitress who lives in Tamarac, filed a lawsuit against\ Doyan in 1993 and waited three years as a state investigation and\ appeals court case against Doyan dragged on. Three other patients\ filed complaints against Doyan with the state, records show.\ \ One said Doyan undressed her during a consultation in his office, then\ put his mouth in her genital area and requested that she perform oral\ sex on him, according to state health department records.\ \ Another woman alleged that Doyan cut his fee by \$800 after she agreed\ to send two friends to him for consultations. She said Doyan then\ failed to perform some of the surgery on her despite taking her money.\ \ Florida\'s Board of Medicine consolidated its four administrative\ complaints against Doyan and revoked his license in November 1995. But\ Doyan didn\'t accept the board\'s punishment.\ \ His lawyer persuaded an appeals court in Tallahassee to allow Doyan to\ continue practicing while his appeal was heard. That took another year\ and Doyan remained licensed until December 1996, when the appeals\ court upheld the state medical board\'s action.\ \ Goodrich cheered the board\'s decision. But she soon found out that\ Doyan would not be paying the jury verdict of \$421,800 she won against\ him in February 1995. Doyan, according to court records, declared\ bankruptcy the same year, leaving Goodrich\'s and three other court\ judgments totaling more than \$3.1 million unpaid.\ \ Doyan took advantage of a state law that allows doctors to operate\ without carrying medical malpractice insurance. Doctors who do so are\ supposed to demonstrate they personally can satisfy a judgment of at\ least \$250,000. They also must post a notice in their offices advising\ patients of their decision.\ \ Doyan posted a sign in his office, but its wording was misleading and\ amounted to \"mispresentation,\" according to a judge\'s ruling in\ another lawsuit brought on behalf of Goodrich.\ \ In any case, he didn\'t have even \$250,000 to hand over. Doyan claimed\ only \$1,100 in assets at the time he filed for bankruptcy, despite\ what the bankruptcy judge called Doyan\'s \"medium to high five-figure\ income.\"\ \ Goodrich figures she will never see a penny. \"He has walked away\ scot-free and I\'m the one with severe scarring on my stomach and my\ breast area,\" she said.\ \ While she remains angry at the state\'s medical disciplinary system,\ Goodrich accepts some of the blame for her predicament.\ \ She regrets never checking with state licensing officials to see if\ Doyan had any special training in plastic surgery to back up his\ advertising, which promised patients they would \"look years\ younger\"and \"at affordable prices.\"\ \ \"I never asked him if he had the qualifications,\" said Goodrich. \"I\ was from the old school. You believe your doctors. Boy, did I get a\ rude awakening.\"\ \ PATIENTS CAN NIP AND TUCK NOW, PAY LATER\ Sun-Sentinel - Tuesday, December 1, 1998\ Author: FRED SCHULTE and JENNI BERGAL Staff Writers\ The face of cosmetic surgery is changing -- customers are getting\ younger, and they\'re more willing to take on thousands of dollars of\ debt to look better.\ \ In 1994, 36 percent of cosmetic surgery clients were somewhere between\ their teen-age years and 35 years old. By 1996, 40 percent were under\ 35, according to the American Academy of Cosmetic Surgery, which\ represents 1,300 doctors nationwide who perform cosmetic operations\ from liposuction to hair transplants.\ \ The number of women under 35 who had tummy tucks, for example, nearly\ doubled between 1992 and 1996, according to the American Society of\ Plastic and Reconstructive Surgeons. Breast implants remain popular\ with younger women; 60 percent of the women who had their breasts\ enlarged in 1997 were under 35.\ \ Most patients quickly discover that cosmetic operations are not\ usually covered by medical insurance, so they must pay out of pocket,\ on a credit card, or through a financing plan. A set of breast\ implants can cost \$3,000 or more in Florida; a face-lift about \$5,000.\ \ \"These teen-agers graduate high school and say, \'Dad, keep the car,\ keep the apartment, we want plastic surgery\',\" said Fred Howard, a\ former cosmetic surgery clinic owner who now markets for a Miami\ Shores center.\ \ Many young people seem willing to pay for surgery on credit, just like\ buying a car or a household appliance.\ \ And it\'s easy to do so. Three of four cosmetic surgeons allow patients\ to finance their procedures, according to the cosmetic surgery\ academy, and there\'s no shortage of companies stepping in to provide\ that financing.\ \ Jayhawk Acceptance Corp., a Dallas-based cosmetic surgery financier,\ offers a \"simple, affordable and immediate way to pay for your\ cosmetic procedure and begin to realize the changes in your life that\ you have always wanted.\"\ \ Jayhawk, which started by financing used cars for people with poor\ credit ratings, charges 9.9 percent interest compounded annually for\ cosmetic surgery. Payments can be extended for as long as three years.\ \ \"Apply Now and change your life!\" reads a Jayhawk Internet ad.\ \ Cooperative Images, based in Pennsylvania, is another finance company.\ Its Internet site advertises no money down and payments as low as \$38\ a month for cosmetic surgery.\ \ \"If you put off having surgery because you couldn\'t afford it . . .\ Now is your chance to make your dream come true,\" the company says.\ \ But some plastic surgeons worry that too much easy credit and\ competition for patients may prompt some of their colleagues to take\ on patients who really can\'t afford their services, or who may be poor\ candidates for a procedure because of chronic health problems or\ obesity.\ \ \"Looking for the quick and easy and cheap, you\'re going to find people\ who have things done that shouldn\'t be done,\" said Dr. William Mullis,\ past chairman of the American Society of Plastic and Reconstructive\ Surgeons\' ethics committee. \"It just doesn\'t seem to pass the sleaze\ test. It\'s a black eye to medicine.\"\ \ Dr. Robert L. Simons, a North Miami Beach surgeon and past president\ of the American Board of Facial Plastic and Reconstructive Surgeons,\ said the high cost of marketing may also lead to an overuse of\ cosmetic surgery.\ \ \"Trying to turn out case after case to meet your advertising budget is\ a very bad thing for this business. It can be very harmful,\" said\ Simons.\ \ But many marketers -- and some doctors -- dispute such criticism and\ say they are simply offering a service that can help everyone, not\ just the rich and famous, to look and feel better about themselves.\ \ \"I don\'t think it\'s an ethical problem, as long as the service is\ delivered in an ethical fashion and there is no secondary gain,\" said\ Dr. Charles Pappas, a plastic surgeon who is medical director of the\ Connecticut-based Aesthetics Medical Management Inc., which manages\ cosmetic surgery centers.\ \ \"If they need to finance it, why not?\" Pappas said. \"Should I own an\ automobile if I couldn\'t afford to pay cash for it, or should I be\ able to get a loan? The credit system is the American way.\"\ \ Piling up debts for elective surgery, like piling up debt for\ anything, can carry legal consequences.\ \ Broward County Court Judge Steven Shutter said he is disturbed that\ some cosmetic surgeons and centers are routinely suing their patients\ in his courtroom -- often over a few hundred bucks.\ \ It\'s not that Shutter thinks doctors don\'t deserve to be paid for\ their services, or that patients should be able to weasel out of\ paying debts they owe.\ \ But the judge said he is uncomfortable that some doctors require\ patients to sign promissory notes agreeing to pay all legal and court\ costs if they don\'t make payments on time. That, Shutter said, is\ unusual in the medical profession.\ \ \"Instead of just money for a tummy tuck, \$500 down, \$250 for the rest\ of my life, I sign something that says if we have to sue you, we\'re\ entitled to court costs and reasonable attorney\'s fees,\" Shutter said.\ \"It\'s a pretty scary thing.\"\ \ MARKETING BLITZ ENTICES PATIENTS - SOME COSMETIC SURGERY SELLING\ STRATEGIES STRETCH LEGAL AND ETHICAL BOUNDARIES.\ Sun-Sentinel - Tuesday, December 1, 1998\ Author: FRED SCHULTE and JENNI BERGAL\ To believe the marketing blitz surrounding cosmetic surgery, Florida\ has a fountain of youth after all.\ \ The come-ons from cosmetic surgery clinics are everywhere -- in the\ Yellow Pages, in newspapers, on TV and radio, on the Internet, even on\ ads bolted to bus benches.\ \ Some target insecure 20-somethings in search of bigger breasts or\ beach-friendly physiques with discount prices and easy-credit terms.\ \ Some surgeons seek out affluent seniors or mid-career executives\ worried they are losing their looks to age and willing to pay \$5,000\ or more in cash for a face-lift.\ \ Others rely on \"before-and-after\" photos to show how easily\ liposuction can swoosh away pounds of unsightly belly fat. One\ liposuction doctor even sells gift certificates.\ \ For the most part, these sales practices do what all advertising and\ marketing is supposed to do: bring in new customers and sell them a\ product. That\'s perfectly legal and ethical for doctors under Florida\ law.\ \ But some cosmetic surgery marketing strategies stretch ethical and\ legal boundaries, may mislead the public about the benefits and\ possible risks of the operations, and could even play a role in\ compromising patient safety, a Sun-Sentinel investigation found.\ \ \"Let the buyer beware,\" said Dr. Fredric Barr, a West Palm Beach\ plastic surgeon and volunteer consultant who helps the state evaluate\ complaints against other doctors. \"The seductive, unbelievably\ unrealistic balloon of fantasy is floated out there, promulgated by\ the media.\"\ \ In Florida, where the numbers of many types of cosmetic surgery\ procedures have doubled in the past five years, hundreds of\ practitioners, from private-practice doctors to investor-owned\ cosmetic surgery clinics, are vying for business.\ \ While no Florida figures are available, one in four plastic surgeons\ nationwide took home \$300,000 or more in 1997, according to a survey\ by Medical Economics magazine.\ \ The fierce competition, some critics worry, may be encouraging\ marketing methods -- such as hefty discounts on second or third\ procedures done at the same time -- that put patients\' health at risk.\ \ \"It\'s like hawking your wares and creating a service that people\ aren\'t even thinking about,\" said Dr. James T. Howell, secretary of\ the Florida Department of Health. \"You\'re no more than a merchant.\ You\'re a business. You might as well have double Green Stamp days.\"\ \ More is not better\ \ Too much of today\'s marketing and advertising suggests that more is\ better, said Dr. Mark Gorney, who has extensively studied\ complications from plastic surgery procedures.\ \ Risks of complications rise sharply when two or more cosmetic\ procedures are offered as part of a package deal, as is often done in\ Florida\'s hotly competitive market, he said.\ \ \"That is a deplorable trend,\" said Gorney, a plastic surgeon who\ practices in Napa, Calif. \"It flies in the face of good surgical\ management and honesty and integrity. Economic considerations are\ replacing surgical judgment and common sense.\"\ \ Packing too much surgery into a single session greatly increases\ operating times, which in turn may push the bounds of safety,\ especially for elderly people or those in poor overall health.\ \ \"I\'m a dinosaur, but I think a warm body and a credit card are not\ sufficient for having plastic surgery,\" Gorney said. \"The patient must\ be a good candidate and want the procedure and be in good health.\"\ \ Reporting an upsurge in deaths following liposuction, the American\ Society of Plastic and Reconstructive Surgeons in February cited\ several risk factors, among them multiple procedures.\ \ \"Careful surgical judgment\" must be used to prevent injuries, the\ statement said, adding, \"Likewise, a combination of procedures may not\ be a problem for one patient but may be inadvisable for another.\"\ \ The group\'s findings come as its members have been reporting steady\ increases in the number of patients who undergo multiple procedures --\ up to 37 percent in 1996 from 30 percent two years earlier, according\ to the society. In Florida, 39 percent of patients had multiple\ procedures last year.\ \ Some plastic surgeons say that multiple procedures can be done safely\ in a medical office, provided the surgeon takes proper precautions and\ the patient is in good health.\ \ \"It all depends on the complexity and the invasiveness of the\ surgery,\" said Dr. C. Roberto Palma, a Fort Lauderdale plastic surgeon\ who is chief of staff at North Ridge Medical Center.\ \ But Dr. Emilio Echevarria, a Tampa surgeon who chairs the Florida\ Board of Medicine\'s surgical care committee, warns that not all\ doctors use good judgment. His panel is discussing a rule that would\ limit the amount of operating time for multiple cosmetic procedures in\ a medical office. A meeting is set for early this month.\ \ California plastic surgeon Gorney blames \"dog-eat-dog\"competition\ among surgeons for increases in the numbers of multiple procedures,\ calling the trend a \"prescription for disaster.\"\ \ Naples plastic surgeon Clyde Balch also said competition for patients\ may cloud the judgment of some surgeons and lead them to overlook\ medical problems such as heart disease or excessive weight that could\ make surgery far riskier.\ \ \"Some physicians who perhaps have a marginal practice are not turning\ away anybody,\" Balch said. \"If the rent is due next week and you don\'t\ have a patient on the books, you may think, `Maybe I shouldn\'t do\ this, but they\'ve got the cash or the check.\' \"\ \ Marketing gets questionable when surgeons or their office staff push\ cosmetic operations, especially ones the patient didn\'t request at the\ outset.\ \ \"I think that it is unethical. People should not be sold an operation.\ You shouldn\'t ask them to undergo a procedure that they didn\'t inquire\ about,\" said Dr. J. Brian Boyd, chief of plastic surgery at the\ Cleveland Clinic in Fort Lauderdale.\ \ The American Society of Plastic and Reconstructive Surgeons, which\ represents about 5,000 members nationwide, agrees. Its ethics\ guidelines forbid \"systematic verbal solicitation\" of patients, noting\ that people \"who have made a deliberate, thoughtful decision without\ undue pressure\" are the best candidates for surgery.\ \ Yet allegations of overzealous marketing have surfaced in medical\ malpractice lawsuits against plastic surgeons in South Florida. Some\ lawsuits have accused surgeons or their marketing staffs of failing to\ advise patients adequately of possible risks, or putting undue\ pressure on patients to have more work done than they intended, or\ discounting prices for patients willing to make a quick decision,\ court records show.\ \ Richard Dion, a former waiter, sued the Florida Center for Cosmetic\ Surgery in Fort Lauderdale earlier this year, claiming he was\ disfigured and unable to work after pectoral implants to bulk up his\ chest became painfully infected.\ \ Florida Center marketing official Jeffry Davis testified in April that\ he gave Dion a hefty discount -- dropping the fee from \$5,000 to\ \$3,000 partly because Dion agreed to have the surgery right away, to\ fill an opening on the center\'s surgery calendar.\ \ \"You know, it\'s like an airplane,\" Davis testified. \"You have an empty\ seat, you know, you put somebody in there. You know, you\'re going to\ pay the rent anyway.\"\ \ Dion has since settled his lawsuit against the center for an\ undisclosed sum. Center officials declined to comment.\ \ Selecting their targets\ \ The Florida Center for Cosmetic Surgery\'s marketing formula is similar\ to many investor-owned clinics. The center, which advertises that it\ performs more cosmetic surgery than any other clinic in Florida,\ handles marketing, arranges consultations and gives patients a choice\ of doctors, who work as independent contractors.\ \ Many centers also target their marketing. The Florida Center\'s\ newspaper ads, for instance, mention that its patients\' average age is\ 30 and that a \"large percentage\" are minorities.\ \ The Florida Center also advertises in local gay publications and has\ offered discounts to people associated with the Povarello Center, a\ Wilton Manors service organization for people with AIDS, court records\ show.\ \ The Premiere Center for Cosmetic Surgery in Coconut Grove also targets\ its marketing, using newspapers, radio, a 30-minute television\ infomercial and the Internet to bring in new customers, especially\ young people getting started in their careers.\ \ Cosmetic surgery is \"no longer only for the rich and famous,\" says the\ center\'s Website. Premiere offers financing plans on an Internet site\ with payments as low as \$50 a month.\ \ Many plastic surgeons in private practice blame marketing campaigns by\ investor-owned centers for persuading patients to place cost and the\ packaging of procedures above all else.\ \ \"We have people who call my office and don\'t ask about my\ credentials,\" said Dr. Gerard Grau, a Fort Lauderdale plastic surgeon.\ \"They just ask about the price, as if they were buying a piece of\ furniture.\"\ \ But Valerie McAllister, a nurse anesthetist who owns the Premiere\ Center, points out that discounts of 50 percent on a second procedure,\ which she offers, are common in the industry.\ \ More patients are asking for more than one operation, McAllister said,\ but not because of discounts or high-pressure sales. \"I think people\ decide once they have something that there\'s more than one thing\ [about their body) bothering them,\" she said.\ \ Many surgeons said they offer discounts of 50 percent off on a second\ procedure to help patients keep fees manageable. Health insurance\ rarely covers nonessential services such as cosmetic surgery, which\ can cost \$5,000 or more out of pocket.\ \ McAllister, who runs the center with her husband, a commerical\ real-estate developer, plans to open cosmetic surgery outlets in\ Weston, Orlando, St. Petersburg and Jacksonville. She said private\ doctors who criticize investor-owned centers are themselves trying to\ dominate the market and drive out competitors.\ \ \"They are upset about our centers because they\'ve seen their practices\ fall off. These doctors need to realize they live in America. It\'s\ free enterprise.\"\ \ Stretching the rules\ \ Florida doctors aren\'t free, however, to say anything they want in\ their advertising and marketing promotions.\ \ Doctors cannot state or imply they have \"received formal recognition\"\ in a medical specialty unless it comes from a certifying board\ approved by the American Board of Medical Specialties or the state.\ \ For cosmetic surgery, that means in Florida that only surgeons\ approved by the American Board of Plastic Surgery or the American\ Board of Facial Plastic and Reconstructive Surgery can advertise that\ they are \"board-certified\" plastic surgeons.\ \ The state Board of Medicine\'s regulations also prohibit doctors from\ suggesting they possess \"qualifications, skills or other attributes\ which are superior to other physicians.\"\ \ Doctors also are forbidden from creating \"false or unjustified\"\ expectations in their ads, or making any statement or claim that\ \"misleads or deceives\" patients.\ \ Violators are subject to sanctions and fines from the Florida Board of\ Medicine, but the board does little to track down offenders and take\ action against them, according to some doctors.\ \ \"There\'s a lot of misleading advertising. I wish the Board of Medicine\ would do something about that,\" said Dr. Steven Rosenberg, a West Palm\ Beach dermatologist. \"Reputable physicians don\'t like to see\ misleading advertisements. It\'s not fair to our profession when you\ have people out there who are snake-oil salesmen.\"\ \ A collection of more than 200 ads from around the state for cosmetic\ surgeons, including dozens from the Sun-Sentinel, showed that some\ appear to stretch the limits of the advertising rules.\ \ Fort Lauderdale plastic surgeon Jerry Lingle, whose license was\ suspended by the Florida Board of Medicine earlier this year for poor\ patient care, described himself as \"a master of surgical artistry,\ renowned for great results\" in his Sun-Sentinel ads. Lingle has\ repeatedly declined to discuss his practice.\ \ Hollywood plastic surgeon Dr. Richard Edison\'s full-page ads in the\ Sun-Sentinel offer \"guaranteed painless procedures.\"\ \ Edison denied the ads are misleading. He said the claim refers to the\ actual procedure, when a patient is under anesthetic, not the\ aftermath. \"We guarantee every patient they will have no pain when the\ operation is performed,\" Edison said. \"Of course there is discomfort\ afterward. I would never claim there is no pain afterward.\"\ \ All patients sign a consent form before their operation that says they\ may encounter \"discomfort/sensitivity,\" Edison said.\ \ Edison\'s advertising drew scrutiny from the Florida Board of Medicine\ in May 1986, records show. The board issued the surgeon a \"letter of\ guidance\" after he advertised \"free\" medical care without \"the\ appropriate disclaimers,\" according to board records. Edison agreed to\ stop using the term \"free.\"\ \ Some surgeons make promises in their ads they may not be able to keep,\ such as guaranteeing patients that they can return to work two to\ three days after liposuction, or that they can travel within a day of\ having the fat-removal surgery.\ \ The Internet, a booming source of marketing for plastic surgeons, also\ contains some spectacular claims. One Naples plastic surgeon, for\ instance, refers to his work as \"magic\" on his Website.\ \ Before and after\ \ The Board of Medicine also has done next to nothing to regulate one of\ the most common -- and controversial -- marketing techniques in\ cosmetic surgery: the use of \"before-and-after\" photos.\ \ Some surgeons call these collections of photos, which may either\ appear in ads or in office consultations, \"brag books.\"\ \ The idea is to show a prospective patient the striking results in\ improved appearance that cosmetic surgery can achieve. Yet there is no\ way for a patient to know whether the pictures shown represent typical\ results or are the surgeon\'s best work.\ \ Some surgeons have pictured patients who are not their own, or shot\ the \"after\" photos using more favorable lighting, flashier jewelry or\ cosmetics in order to make the subjects appear more attractive. Such\ practices are unethical, according to the American Society of Plastic\ and Reconstructive Surgeons. The society also advises its members to\ tell patients if the photos \"are above normal expectations\" for a\ cosmetic procedure.\ \ Grossman, the Florida Board of Medicine\'s attorney, said regulators\ have a tough time disciplining physicians who use questionable photos\ of their results unless they are accompanied by grossly exaggerated\ claims, such as \"We\'ll do a makeover and you\'ll be Madonna.\"\ \ But California\'s medical board in January announced that it would step\ up enforcement against deceptive ads for cosmetic surgery that fail to\ mention that the \"after\" surgery pictures \"simply could not have been\ accomplished by one procedure.\"\ \ Some Florida plastic surgeons take care to include caveats along with\ photos of actual patients.\ \ Boca Raton plastic surgeon Daniel Man published a book in 1997 titled\ The Art of Man showing about 60 patients he\'s operated on, giving\ their names and short profiles of each. The book notes that patient\ photos \"are not a guarantee as to individual results, as each patient\ is different and unique, and results may vary.\"\ \ Another technique is the use of high-tech computer imagers to create\ \"before-and-after\" pictures of each patient who comes in for a\ consultation with a cosmetic surgeon.\ \ The American Society of Plastic and Reconstructive Surgeons considers\ the use of imagers an acceptable marketing tool, although only about\ 25 percent of the society\'s members use them, according to the group\'s\ statistics.\ \ But a number of Florida surgeons consider them an indispensable\ marketing tool. For instance, Dr. Richard Nazareth, a plastic surgeon\ in Altamonte Springs, advertises free and full-color \"preview imaging\"\ for prospective patients eager to see how they would look. Nazareth\ describes the computer images as \"in essence a look into their\ future.\"\ \ Like Nazareth, most cosmetic surgeons who use them offer preview\ imaging for free. Dr. Lawrence M. Korpeck, a Boca Raton plastic\ surgeon whose newspaper ads ask the question \"Are your breasts the\ size and shape you want them to be?\" refers to the free images as a\ \"\$125 value.\"\ \ Korpeck said he put the dollar figure in the ad because some patients\ say other cosmetic surgeons have charged them a fee for the\ consultation or the imaging.\ \ \"The value of the time we spend with them is worth \$125,\" Korpeck\ said. \"That ad just shows people the value they\'re getting.\"\ \ Some plastic surgeons hesitate to use the imaging devices, however.\ They say that every person\'s body heals differently, and it sometimes\ is difficult to tell in advance who can tolerate procedures well, or\ exactly how a person will look after the surgery.\ \ \"I don\'t want to give patients a false impression,\" said Dr. Charles\ Messa, a Tamarac plastic surgeon. \"You can\'t 100 percent predict how\ someone will be. If you show them a whole new face and don\'t achieve\ that, you get an unhappy patient.\"\ \ Filtering the hype\ \ Even staunch critics of cosmetic surgery marketing say that a good\ deal of the blame lies at the feet of the media that accept misleading\ ads -- and the patients who don\'t do their homework before they agree\ to go under the knife.\ \ State consultant Barr said the media have a responsibility to take\ steps to check out the veracity -- or legality -- of the claims made\ by a physician or cosmetic surgery clinic.\ \ Barr said the media happily take the money of cosmetic surgeons whose\ ads are deceptive. But when the surgeons get in trouble by maiming\ their patients, he said, \"the media wonders, `Oh, my. How did it get\ to this point?\' The hypocrisy of it. It\'s a disgrace.\"\ \ Shelly Greenberger, a Sun-Sentinel vice president and advertising\ director, said the newspaper does not knowingly accept any advertising\ that violates state law or makes claims that mislead readers. However,\ he said, the newspaper lacks the knowledge or expertise to decide\ whether ads placed by physicians meet state requirements.\ \ \"We have to rely on those people whose job it is to regulate\ [physicians) to look at it and say it\'s illegal or exaggerated,\"\ Greenberger said. \"When I am informed by any authority of those kinds\ of situations, I look into it.\"\ \ Greenberger said he was not aware of any complaints to the newspaper\ concerning plastic surgery advertising or any instance in which a\ plastic surgery ad had been canceled or rejected for publication.\ \ The newspaper does not break out advertising revenues by the type of\ medical specialty, Greenberger said, and thus he could not provide a\ dollar figure for cosmetic surgery ads. A check of the newspaper on a\ recent Sunday and Monday found a total of 18 cosmetic surgery ads.\ \ Patients also need to take some responsibility, doctors say, by\ learning how to sift through advertising hype and picking the surgeon\ most qualified to do the procedure.\ \ So far, that does not appear to be happening, however.\ \ In October, the American Society of Plastic and Reconstructive\ Surgeons issued a study showing that the \"bedside manner\" of doctors\ was more important to patients than the surgeon\'s technical skills.\ \ \"Most patients do not know how good a doctor\'s surgical skills are,\"\ said Dr. Kevin C. Chung, a University of Michigan professor of plastic\ surgery. \"What is most important to the patient is that initial\ encounter and how the doctor presents himself or herself.\"\ \ Patients like that make a big mistake, said Dr. Andrew Astrove, a Boca\ Raton anesthesiologist who has spent more than a decade working with\ cosmetic surgeons in Florida.\ \ Astrove said few patients ask tough questions about a cosmetic\ surgeon\'s operating room facilities and the qualifications of staff\ assisting during the procedure and after.\ \ \"Patients like the surgeon\'s tie, cologne and the flair of his office,\ and they forget to ask about the other parts,\" Astrove said. \"It\'s\ frightening. The public doesn\'t know what goes on.\"\ \ A CASH COW OR A LOUSY BUSINESS?\ Sun-Sentinel - Tuesday, December 1, 1998\ Author: FRED SCHULTE and JENNI BERGAL Staff Writers\ Walter Shaw was a reformed master burglar and aspiring movie producer\ with friends who had cash to invest.\ \ Fred L. Howard was a marketing consultant who once helped manage the\ office of a Miami surgeon who later was convicted of manslaughter in\ the death of a patient after a penis implant.\ \ Together they saw a bright future in South Florida\'s exploding\ cosmetic surgery industry.\ \ In the summer of 1996, Shaw and Howard opened The Center for Laser\ Surgery at the Galleria. It sat on a palm-dotted lot on a quiet street\ tucked behind Fort Lauderdale\'s Galleria Mall, just a short stroll\ from the Atlantic Ocean.\ \ Shaw, 50, said he soured on the industry and got out in February 1997,\ about the time the center officially changed its name to A New You\ Institute of Cosmetic Surgery.\ \ \"Florida is nothing but a sunny place for shady people and this is the\ shadiest of businesses around,\" Shaw said.\ \ Howard disagrees. He\'s still a big booster of cosmetic surgery and\ sees a bright future for the industry. \"The market today is so vast,\ and it just keeps getting bigger,\" he said.\ \ Howard said he sold his interest in the Fort Lauderdale center earlier\ this year. He now is marketing a new cosmetic surgery center in Miami\ Shores called A New You Center for Cosmetic Surgery.\ \ Howard said Shaw just didn\'t give the Fort Lauderdale center enough\ time to find a niche and establish itself, or spend enough on\ marketing and advertising, a key ingredient for success.\ \ Shaw said they spent \$560,000 provided by investors Michael M. Miller,\ a founder of Seminole Indian bingo in Hollywood who has since died,\ and another man neither Shaw nor Howard would name. Howard, however,\ says the investors put up only about \$250,000.\ \ Both Shaw and Howard agree that the money remodeled the office and\ paid for leases on medical equipment. No permits or inspections were\ required, other than an occupational license to begin operating.\ Liposuction and breast implants became the two best sellers once the\ center expanded from doing only laser surgery.\ \ Shaw said the center spent about \$70,000 for advertising, much of it\ on brief television ads that ran during soap operas or daytime talk\ shows.\ \ But Shaw said many sales were clinched on the premises by female\ marketers with implants to show off. He said they were paid\ commissions of 20 to 25 percent of the surgical fee.\ \ \"I had women sell the procedure,\" Shaw said. \"They would open their\ blouse, take their tops off and say, \'Look what I had done!\' \"\ \ Getting surgeons was not a problem. \"They\'re just salaried employees,\"\ Shaw said. \"They come in for a couple of hours, do the surgery and\ leave. You pay them in cash.\"\ \ Shaw said surgeons, some of whom moved from one center to another as\ free-lancers, were paid about \$1,500, depending on the procedure. An\ anesthesiologist who handled pain relief also was paid for each\ procedure, according to Shaw.\ \ But Shaw, who ran his film production company out of an office in the\ back of the clinic, found there were pitfalls that ultimately caused\ him to walk away from the center.\ \ Collecting fees, for instance, was not always easy. Some patients who\ were extended credit tried to get out of paying if they were unhappy\ with the results, he said. He got fed up with patients, some of them\ strippers, who stiffed him, or tried to.\ \ \"We had very few society types,\" Shaw said. \"They would go to a real\ plastic surgeon with a real office. This was like a used-car lot.\"\ \ Howard disputes that view. He said the center had excellent doctors\ who took responsibility for providing high-quality medical care.\ \"We\'re in the marketing business,\" Howard said. \"We give the doctors\ the patients and leave it to them to handle [the surgery).\"\ \ Howard has worked at a number of cosmetic surgery centers over the\ last decade, either as an employee or an owner.\ \ He helped market the cosmetic surgery practice of Dr. Ricardo Samitier\ in Miami-Dade County almost a decade ago. He continued to have an\ on-and-off business relationship with Samitier for several years. In\ 1992, state officials revoked Samitier\'s medical license after the\ death of singer Claudio Martell following liposuction and a penis\ implant. Samitier was convicted of manslaughter two years later. By\ that time, Howard was working at a Fort Lauderdale cosmetic surgery\ clinic, of which he was formerly the president. That clinic is now\ called the Florida Center for Cosmetic Surgery, which claims to be the\ largest operation of its kind in the state.\ \ Howard stayed on to work at the Florida Center, driving patients home\ after their operations, according to court records. He left to join\ Shaw in opening what later became A New You Institute of Cosmetic\ Surgery just a few blocks away. By contrast, it was Shaw\'s first\ venture into medicine. A South Florida media staple in the early\ 1980s, Shaw often boasted to reporters of his ties to organized crime\ figures -- claims mostly dismissed by authorities.\ \ Shaw still reminisces about his days breaking into the homes of the\ rich and famous. He served 111/2 years in prison before re-emerging in\ the 1980s as a reformed burglar who made a video to assist the public\ in thwarting the kinds of crimes he said he used to commit.\ \ Most recently, Shaw surfaced in the sex scandal involving Catholic\ priest Father Thomas Foudy, who was sued along with the Archdiochese\ of Miami by a woman who alleged she and Foudy had a steamy affair.\ \ Shaw said he learned of the woman\'s tale while she was undergoing\ cosmetic surgery at the center.\ \ Intrigued by the movie potential, Shaw said, he signed her to a\ contract giving him rights to film her life story, just as the woman\ prepared a confidential agreement to settle her suit. The archdiocese\ had agreed to pay the woman \$200,000, according to news reports.\ \ But Shaw blew her deal when he came forward and said the woman\ couldn\'t sign a confidential agreement because she was under contract\ to his film studio to make the movie.\ \ The lawsuit between the woman and the church has since been settled\ for terms that were not disclosed. Shaw\'s movie deal with the woman\ dissolved.\ \ His latest project, Shaw said, is a Hollywood movie based on his past\ life of crime and notoriety, sort of an anti-Goodfellas in which the\ hero sees the light and goes straight. Shaw says he\'ll never get into\ the cosmetic surgery field again.\ \ \"It\'s a lousy business,\" Shaw said. \"The only money I made the whole\ time was when we closed the place down and offered valet service for\ the Air & Sea Show. We got 20 bucks a car.\"\ \ Howard, however, expects to remain active in the growing market for\ cosmetic surgery.\ \ \"It was just the rich and famous 12 years ago. Today, it\'s everyone\ down to your bottom level of income,\" Howard said. \"People will sell\ their house to get their surgery.\"\ \ His latest area of interest: marketing surgery to approve the\ appearance of the vagina.\ \ \"It\'s one of the biggest procedures in Beverly Hills and New York\ right now,\" Howard said. \"It\'s the new hot area.\"\ \ IN THE BUSINESS OF MARKETING BODY MAKEOVERS\ Sun-Sentinel - Tuesday, December 1, 1998\ Author: FRED SCHULTE and JENNI BERGAL Staff Writers\ Paul Refkin and Jeffry Davis once sold vintage car kits through a\ telemarketing firm in Miami.\ \ Today, they\'re in the business of selling people new bodies at the\ Florida Center for Cosmetic Surgery in Fort Lauderdale.\ \ The center, which says in newspaper advertising that it is the state\'s\ largest-volume cosmetic surgery clinic, promises patients top-quality\ results at affordable prices. It plans to open branches in Miami-Dade\ and Palm Beach counties.\ \ But Broward Circuit Court records and Florida Board of Medicine files\ show that the surgery center has been the target of more than a dozen\ medical malpractice lawsuits filed since 1996, most of them resulting\ from the work of a surgeon who has since left the center.\ \ That surgeon, Dr. Jerry Lingle, is one of three doctors retained by\ the center in recent years who have faced state disciplinary actions\ against their medical licenses.\ \ Refkin would not comment. He canceled an interview scheduled at the\ center, saying he was \"too busy\" to meet that day. Asked if the\ interview could be rescheduled, Refkin said: \"We\'d prefer not to do\ it. We don\'t need the publicity.\" Davis did not respond to a letter\ seeking an interview.\ \ Barbara Dame, the center\'s risk management consultant, said the center\ is seeking accreditation, tightening quality standards and is proud of\ the team of doctors it now has in place.\ \ \"Everybody\'s been evaluated and they are all fine surgeons,\" Dame said.\ \ The Sun-Sentinel used state Department of Health records, court files\ and depositions from a medical malpractice lawsuit to trace the\ history of the center and the people who run it.\ \ Tactics questioned\ \ During the early 1980s, Refkin and Davis were vice presidents at\ Classic Motor Carriages, which sold fiberglass replicas of vintage\ autos, such as Mercedes roadsters. Customers paid about \$8,000 for the\ kits, which could be assembled and mounted onto an auto chassis.\ \ Classic\'s telemarketing tactics came under fire from Florida Attorney\ General Bob Butterworth. The firm ended an attorney general\'s\ investigation in October 1985 by signing a legal promise to abide by\ consumer protection laws. The state review was sparked by complaints\ that some buyers never received parts or were misled by high-pressure\ sales tactics. Company officials did not admit wrongdoing in signing\ the agreement.\ \ Refkin and Davis left Classic Motor Carriages in 1987 to form their\ own kit-car concern, which sold its assets in May 1991 to Classic\ Roadsters Inc., of Fargo, N.D., court records state.\ \ Davis was president of Classic Roadsters. Refkin was head of sales and\ marketing, according to court records and the deposition of a senior\ executive with the company.\ \ Classic Roadsters filed for bankruptcy in September 1992. Davis\ pleaded guilty in April 1995 to federal charges of making false\ statements to obtain a \$250,000 loan for Classic Roadsters and failing\ to pay payroll taxes of about \$280,000 owed by the firm, court records\ state. He served five months in prison in Miami.\ \ Davis was at work in the cosmetic surgery business before he served\ his sentence.\ \ Part-time surgeons\ \ The Florida center, which takes up three suites on the second floor of\ the Galleria Professional Building on Middle River Drive, advertises\ that it \"performs more cosmetic procedures than any other group in\ Florida.\" Seven cosmetic surgeons work as \"independent contractors,\"\ most of them part time. The center has three operating rooms.\ \ Because the center is privately owned, it has no obligation to release\ financial or business information to the public.\ \ However, its sales volume is attested to by a California company that\ manufacturers breast implants. The center is \"certainly one of our\ larger customers,\" said Gary Mistlin, senior vice president of the\ Mentor Corp. Mistlin said the center is in the top 25 of more than\ 3,000 of its customers nationwide.\ \ Dr. Timothy Alexander, one of the center\'s seven surgeons, said he\ typically performs four or five operations there in a day. Overall, he\ said, doctors at the center do about 40 to 50 cosmetic operations a\ week on patients who range in age from their late teens to their\ mid-70s.\ \ The center is owned by Refkin\'s wife, Beverly, according to\ depositions in court records. Beverly Refkin is a corporate vice\ president and works there four days a week, she testified in June.\ \ Paul Refkin, 70, testified in an April deposition that he has been\ retired for three years. However, he also stated that he remains\ involved in many key business decisions at the center and likes \"to be\ there to oversee my wife\'s investment.\" He testified that he receives\ no salary or compensation from the center and has no job title.\ \ Davis also has said he has no job title at the surgery center. But in\ a deposition, he described his role as an administrative job in which\ he schedules patients and makes sure that \"proper patient relations\ are maintained.\"\ \ The center\'s president is Sherman Clay, who worked with Refkin and\ Davis at Classic Roadsters, according to a deposition he gave in a\ medical malpractice lawsuit against the center. In that deposition,\ Clay said he has no background in medicine but manages the surgery\ center\'s day-to-day operations. \"You don\'t have to be a brain surgeon\ to run a medical center,\" he said.\ \ `Charming\' qualifications\ \ Clay and Refkin, who also has no medical background, helped make a key\ medical decision in the fall of 1994 when they struck up a deal with\ plastic surgeon Lingle. At the time, Lingle was relocating to Fort\ Lauderdale from Kentucky.\ \ Refkin and Clay testified that they brought Lingle on board after\ reviewing his practice record, including a lengthy Kentucky Board of\ Medicine investigation of a patient who died in Lingle\'s Louisville\ office in 1985 while undergoing a nose job. A hearing officer found\ Lingle negligent, but the Kentucky medical board took no formal\ disciplinary action.\ \ Refkin said he found Lingle\'s qualifications -- including his board\ certification in hand surgery and general plastic surgery --\ impressive. He also said he thought Lingle\'s Southern drawl was \"very\ charming\" and that \"women would like it.\" Lingle worked as an\ independent contractor at the center and was paid from 25 to 35\ percent of the net proceeds from patient fees, according to\ depositions.\ \ But Lingle\'s two-year tenure at the Florida center prompted nine of 13\ medical malpractice lawsuits filed since 1996 against the center,\ Broward Circuit Court records show. Both Lingle and the center have\ denied the lawsuits\' allegations in court pleadings.\ \ The suits against Lingle included one from a woman who said she was\ left paralyzed on the right side of her face and unable to close an\ eye after a face-lift, and several women who alleged they were\ severely scarred after having breast implants. Lingle, who set up his\ own practice after leaving the center in November 1996, declined to\ comment.\ \ The Florida Department of Health cited the cases of five patients\ Lingle had operated on at the Florida Center for Cosmetic Surgery when\ the agency filed an emergency suspension of his license in May. Under\ an agreement with the Board of Medicine, Lingle was allowed to return\ to practice in late November.\ \ The center has been the target of lawsuits stemming from the work of\ other surgeons who have done operations there in recent years, court\ records state.\ \ Plastic surgeon Alexander, who works at the Florida center part time,\ said the numbers of malpractice suits should not be used to judge the\ center\'s quality of medical care.\ \ \"Anybody can sue anybody,\" he said. \"In plastic surgery, someone\'s\ self-perception of a good result is very subjective.\"\ \ The center has \"very good doctors,\" Alexander said. \"I\'m very\ comfortable working here. We have very few problems, considering the\ volume we have.\"\ \ The latest of 13 medical malpractice cases against the Florida center\ since 1996 was filed in October on behalf of Phyllis Scott, a\ 64-year-old retired union payroll manager who had agreed to pay the\ center \$10,000 for several procedures.\ \ She had the first phase of the surgery in December 1997, but at the\ end of the five-hour eye-lift operation she suffered brain damage from\ lack of oxygen, according to the lawsuit.\ \ Scott spent 10 days in a coma. When she awoke, she was permanently\ brain-damaged, according to the lawsuit. She now has the mind of a\ first-grader and cannot walk well, said her attorney, Alexander Clark,\ of Fort Lauderdale.\ \ Said Clark: \"She\'s delusional and can\'t even remember how many\ children she has.\" Dame, the Florida center\'s risk management\ consultant, said she could not comment on a pending lawsuit.\ \ `A nurse screwed up\'\ \ Alexander, who was not involved in the Scott case, is one of two\ doctors currently working at the center who have been the subject of\ disciplinary action by state medical-licensing officials, according to\ state records.\ \ The Florida Board of Medicine issued Alexander a letter of guidance in\ June 1991 after formaldehyde was mistakenly injected into the eye of a\ woman who was having eyelid surgery. Alexander\'s insurance company\ paid \$750,000 to settle a malpractice suit filed by the woman,\ according to state insurance records.\ \ Alexander said he was held responsible for the error of a nurse. \"A\ nurse screwed up. It was an accident,\" he said. \"The person healed up\ fine. It was no big deal.\"\ \ The medical board also fined Alexander \$1,500 in June 1995 after he\ was found to have kept inadequate records and no written consent form\ for a 57-year-old woman\'s face-lift and eyelid surgery.\ \ Alexander said the records existed but were lost by the center where\ he then worked. \"I had no control over them,\" he said.\ \ Both state Board of Medicine complaints against Alexander were filed\ before he started working for the Florida Center, records show.\ \ Another Florida Center part-time physician disciplined by the state\ medical board is plastic surgeon Robert Hunsaker.\ \ Hunsaker was accused of sexual misconduct by three patients when he\ worked at another cosmetic surgery center. In each case, Hunsaker\ allegedly placed his penis in the patient\'s hand. The state suspended\ Hunsaker\'s license in December 1996, but an administrative law judge\ believed the physician\'s denials and dismissed the state\'s complaint\ in July 1997.\ \ The state gave him back his license in October 1997. The state filed a\ new complaint against Hunsaker in March after a 19-year-old patient\ made similar allegations of sexual misconduct. That case is pending.\ \ On Nov. 5, the state filed yet another complaint accusing Hunsaker of\ sexual misconduct against three other women patients, ranging from a\ 43-year-old woman who had a nose job to a 21-year-old who had breast\ implants.\ \ All of the allegations against Hunsaker arose from operations he\ performed at a Miami-Dade cosmetic center where he previously worked.\ Hunsaker did not respond to repeated requests for comment.\ \ Risk management consultant Dame said that Hunsaker was \"proved\ innocent\" by the state medical board and has done \"outstanding work\"\ at the Florida Center.\ \ CLAMPING DOWN ON PLASTIC SURGEONS - MEDICAL BOARD PROMISES TO CLOSE\ SURGERY LOOPHOLES.\ Sun-Sentinel - Wednesday, December 2, 1998\ Author: Fred Schulte and Jenni Bergal\ Cosmetic surgery in Florida badly needs a makeover, many doctors and\ state health officials say.\ \ A Sun-Sentinel investigation this week documented 34 deaths in Florida\ associated with plastic surgery since 1986. Thirteen people died in\ the past two years - most of them after multiple cosmetic procedures,\ such as liposuction and a face-lift, done at the same time in a\ doctor\'s office.\ \ Florida\'s Board of Medicine, which licenses doctors, is considering\ tighter medical regulations and other means to speed up disciplinary\ hearings in light of rising complications. A hearing is set for this\ month.\ \ \"When somebody dies, we\'ve got to look at it and say what can we do?\"\ said board member Dr. Emilio Echevarria, a Tampa general surgeon who\ heads the board\'s surgical care committee.\ \ But trying to make cosmetic surgery safer for the public will force\ state health officials, the Board of Medicine and the Florida\ Legislature to face a number of contentious questions - with no\ guarantee that more rules will be a cure-all.\ \ The issues include:\ \ Who should be permitted to perform cosmetic surgery? Under current\ law, anyone can open a cosmetic surgery center and hire any licensed\ physician to operate. There is no requirement that the doctor be\ trained in cosmetic surgery or have privileges to perform it in a\ hospital, a standard yardstick of minimal competence.\ \ -- What new safety standards are needed? The state does not spell out\ the types of surgery that can be safely performed in a medical office\ rather than a hospital, even though as many as nine of every 10\ cosmetic procedures occur in medical offices.\ \ -- How can state health agencies best track cosmetic surgery\ complications and deaths? The state lacks a system to collect this\ data and use it both to advise the public of cosmetic surgery risks\ and to discipline doctors who do substandard work.\ \ -- How can the state assure injured patients of adequate compensation?\ State law allows doctors to operate without any malpractice insurance.\ At least four South Florida plastic surgeons in recent years have\ avoided malpractice judgments after they dropped their insurance\ policies or declared bankruptcy.\ \ `Corrupted\' profession\ \ Plantation plastic surgeon Steven Eisenstadt isn\'t hopeful about the\ prospects for reform. He said he plans to leave Florida because he\ feels his profession has been \"corrupted\" by what he sees as the\ state\'s failure to impose strict medical standards.\ \ \"The state has been enormously lax [in policing the industry), and\ that has given bona-fide plastic surgeons a black eye,\" he said.\ \ Eisenstadt said he\'s fed up with hearing about patients maimed by\ cosmetic surgeons he feels are not qualified. And he\'s not bashful\ about speaking out on the need for reform. \"Florida has become the\ dust bin for any incompetent in the country,\" he said.\ \ Eisenstadt argues that state officials must start insisting that\ physicians who call themselves plastic surgeons be properly trained.\ \ Eisenstadt, 52, feels he\'s earned the right to criticize. A general\ surgeon, he returned to medical school to train in the fine points of\ plastic surgery.\ \ Once he completed his three-year residency, he passed a written and\ oral examination by the American Board of Plastic Surgery, one of two\ plastic surgery boards recognized by most medical authorities and the\ state of Florida.\ \ He now is a member of the American Society of Plastic and\ Reconstructive Surgeons, whose members consider themselves the elite -\ and the only group fully qualified to perform cosmetic surgery.\ \ These plastic surgeons say the big money in vanity care is pushing\ many doctors whose incomes have been slashed by HMOs into plastic\ surgery - without first getting the proper training.\ \ \"We go through so many hurdles,\" said Dr. Laurence I. Arnold, a past\ president of the Broward County arm of the Society of Plastic and\ Reconstructive Surgeons. \"It\'s not right for someone to open an office\ and do the same thing that we do. Anybody with an MD degree can do\ surgery until something [bad) happens. That makes me sick.\"\ \ The opinions of these \"elite\" plastic surgeons make some competitors\ queasy. Ear, nose and throat specialists, dermatologists and other\ doctors argue they also are qualified to perform many types of\ cosmetic surgery. They accuse plastic surgeons of needlessly alarming\ the public and trying to drive them out of business.\ \ \"It\'s a turf battle,\" said Dr. Douglas Dedo, an ear, nose and throat\ specialist from Palm Beach Gardens who has been doing cosmetic surgery\ for 20 years. \"It gets down to the dollar. The plastic surgeons don\'t\ want competition. They feel they are the only ones who should do it.\"\ \ Both sides of the dispute over training and credentials can find\ evidence to support their arguments.\ \ In a computer study of more than 1,100 Florida medical malpractice\ claims, the Sun-Sentinel found that training and credentials don\'t\ guaratentee a good outcome for the patient.\ \ For instance, claims records show that a small number of doctors with\ minimal plastic surgery training - and no board certification - have\ been blamed in malpractice claims for causing serious patient injuries\ and deaths in recent years. The records also show that a few Florida\ doctors who turned to cosmetic surgery did so after careers in other\ medical specialities that were marred by malpractice actions.\ \ But overall, more than 80 percent of the plastic surgeons with\ multiple medical malpractice claims are board-certified in the\ specialty, which means they completed at least five years of training\ in surgery, insurance records show.\ \ Many plastic surgeons believe that the only doctors who should be\ performing comsetic surgery in their offices are the ones who are\ allowed to do the same procedure at a hospital.\ \ Hospitals require surgeons to demonstrate that they are properly\ trained to perform an operation before allowing them to do it.\ Hospitals verify training, practice history and overall competence\ before extending operating privileges to a surgeon. By contrast, any\ licensed physician can perform cosmetic surgery in a medical office.\ \ Requiring cosmetic surgeons to have hospital privileges would force\ some doctors out of the cosmetic surgery field because hospitals shy\ away from granting surgical privileges to nonsurgical specialists,\ such as dermatologists.\ \ But the proposition has the support of Department of Health Secretary\ James T. Howell, a licensed physician who has worked in government\ administrative posts for nearly 30 years.\ \ \"If I went to Broward General Medical Center and said I want to do\ plastic surgery, they would laugh me out of there,\" Howell said. \"But\ I could put up my shingle out on Andrews Avenue and do the same\ procedures in an office.\"\ \ Board lacks answers\ \ The Florida Board of Medicine says it will tighten controls on office\ surgery, but what form the new regulations will take is anybody\'s\ guess. The board\'s surgical care committee, chaired by Tampa surgeon\ Echevarria, has held three hearings this year to consider new\ regulations. A fourth is set for early this month.\ \ So far the hearings have produced little consensus among the doctors\ who have dominated the sessions. Echevarria said his committee is\ struggling to balance its mission to protect the public against the\ wishes of doctors who dislike state interference in their practices.\ \ \"It\'s like pulling teeth getting things through,\" said Echevarria.\ \"The good guys that don\'t get into trouble object to a lot of these\ things. They figure it\'s more bureaucracy and control.\"\ \ Yet some new state requirements are likely, according to Echevarria.\ One is accreditation. To become accredited, a surgery center must meet\ standards for equipment, training of personnel, medical record-keeping\ and other quality measures. Nationally, most doctors who seek\ accreditation for their offices win it for a three-year period. Three\ national groups conduct accreditation reviews.\ \ California has required accreditation of office surgery units since\ July 1996; three other states - Nevada, Maryland and Georgia - also do\ so.\ \ Accreditation or some sort of state inspection and certification\ system for surgery centers appeals to quality-conscious surgeons\ looking for ways to distinguish their office operating suites from\ competitors.\ \ \"Every single place where you can sustain injury should be certified\ by the state,\" said Dr. H. Michael Bass, a Coral Springs plastic\ surgeon. \"A lot of doctors don\'t want that government intrusion, but\ that is shortsighted. We need to protect the public and take a\ responsible attitude.\"\ \ In Florida, 51 centers, half of them in South Florida, are accredited\ on a voluntary basis by the American Association for Accreditation of\ Ambulatory Surgery Facilities, one of the three national review\ groups. Some members tout their accreditation status in advertising.\ \ Yet other doctors are not persuaded that requiring accreditation,\ which can cost from about \$1,000 to \$10,000 depending on the\ accrediting group selected, ensures safer conditions for patients.\ \ \"I\'m not sure what we are doing will change the [injury) statistics,\ or prevent poor judgment by doctors,\" said Dr. Janee Steinberg, a\ Lauderdale Lakes dermatologist. \"That\'s a question I brought up before\ the board and nobody answered.\"\ \ Nor does the board have answers yet to other perplexing questions,\ such as what limits it should place on the types and duration of\ operations allowed in offices, and who is a good candidate for\ surgery. Most authorities agree that risks of complications and deaths\ soar when procedures are combined into lengthy sessions lasting eight\ to 10 hours or more, or when patients have chronic health problems.\ \ The surgery committee is discussing whether to require that so-called\ \"large-volume liposuction,\" in which major amounts of fat are removed,\ be performed in hospitals, not medical offices.\ \ California, the state with the greatest number of cosmetic operations,\ already has clamped down on office liposuction. In July, officials\ there recommended a moratorium on \"large-volume\" liposuction in\ medical offices following the death of an Orange County woman in 1997.\ The procedures are \"experimental and can be extremely risky,\" Dr.\ Robert del Junco, chairman of a surgery committee of the Medical Board\ of California, wrote in a July memo.\ \ The New Jersey Board of Medical Examiners earlier this year took even\ sterner action by imposing a comprehensive code of standards for\ office surgeons, ranging from requiring that doctors have hospital\ privileges to directing that doctors properly evaluate the health\ status of patients prior to operating.\ \ The rules require surgeons to refer people at high risk of\ complications, such as the obese or patients with severe heart or lung\ disease, to a medical specialist for an evaluation before an\ operation.\ \ New Jersey also requires surgeons to report to the state any patient\ death, complication or \'untoward event\" that stems from operations\ performed in their offices.\ \ Death reports sought\ \ Florida officials also want to set up a system for reporting and\ tracking deaths and complications following office surgery. The\ Department of Health has drafted a bill to require such reports and\ hopes to persuade the Florida Legislature to pass it when it convenes\ next year.\ \ The bill would require doctors in private practice to report to the\ state all deaths and surgical blunders within 15 days of their\ occurence. Florida hospitals already file such reports.\ \ \"Requiring reports by physicians involved in office incidents will\ increase the board\'s knowledge of potentially unsafe physicians,\"\ reads a Department of Health legislative report from September.\ \ The proposal also obligates doctors who treat a patient injured by\ another physician to report the colleague. That could have a\ significant impact on plastic surgeons, some of whom say they are\ routinely called upon to fix the mistakes of their colleagues.\ \ The health agency\'s proposal is expected to face opposition from the\ Florida Medical Association, which argues that it would merely\ increase paperwork and burdensome red tape for private doctors.\ \ \"Our primary concern is patient safety. But this just may add another\ layer of bureaucracy and reporting without making it better for the\ patient,\" said Dr. Patrick Hudson, an Orange Park physician who chairs\ the medical association\'s Council on Medical and Socioeconomics.\ \ Department of Health Secretary Howell plans to press ahead with the\ proposal anyway. He also wants to set up a system similar to that used\ by the Sun-Sentinel to document 34 deaths following plastic surgery in\ Florida since 1986, 13 of them since 1997. The newspaper used a\ combination of autopsy reports from medical examiners, lawsuits and\ Florida Department of Insurance medical malpractice claims.\ \ \"We need to get with the medical examiners,\" Howell said. \"You [the\ newspaper) probably found deaths that we don\'t know about. That\'s a\ hell of a note.\"\ \ California\'s board of medicine also is trying to develop a system for\ using medical examiners\' reports to track cosmetic surgery deaths. Its\ office surgery committee wants coroners to report to the board of\ medicine all unexpected deaths from outpatient surgery \"regardless of\ whether or not physician discipline is at issue.\"\ \ Fines unpaid\ \ Some families of patients who have died or been injured after cosmetic\ surgery think the state of Florida also must do more to protect their\ financial interests.\ \ Florida law permits doctors to practice without malpractice insurance\ if they advise their patients of that fact and can personally satisfy\ a malpractice judgment of as much as \$250,000. They either must have\ the money in escrow or have a letter of credit.\ \ But some cosmetic surgeons who failed to meet those requirements have\ faced little punishment from the state medical board, records show.\ \ Dr. Jerome Craft, a plastic surgeon whose office overlooks the\ Intracoastal Waterway in West Palm Beach, was fined \$500 by the\ medical board in December 1991 after the board accused him of being\ unable to document that he advised patients he lacked any malpractice\ insurance, board records show.\ \ Craft said he posted a sign informing patients he had chosen not to\ carry insurance. Somehow, he said, the sign was removed while his\ office was being redecorated and was not put back up. Craft said he\ now carries malpractice insurance.\ \ Craft received a light penalty from the medical board because nobody\ was injured, said board attorney Allen R. Grossman.\ \ But in other cases, patients who claimed injuries from cosmetic\ surgery didn\'t find out until they tried to file a lawsuit to collect\ damages that the surgeon either had no insurance or could not show\ that he had the means to satisfy a court judgment.\ \ Take the case of Carol Stettner, who alleged she suffered a severe\ infection and deformity following breast surgery performed by Dr.\ Melvin Propis, of Plantation, in March 1995. Stettner sued Propis in\ Broward Circuit Court, claiming not only did he not carry malpractice\ insurance, he also had no escrow account or letter of credit.\ \ Propis disputed Stettner\'s allegations, calling the case a \"nuisance\ suit\" and saying he settled it this year for \$10,000. He said that he\ does have the means required by law to satisfy a court judgment,\ although he does not carry malpractice insurance.\ \ \"I want to have malpractice. If I do make a mistake and someone is\ hurt, I want to compensate them,\" Propis said. \"But I can\'t pay\ \$80,000 a year for a \$250,000 policy.\"\ \ Some injured patients have been been awarded large judgments by courts\ or juries only to watch the surgeon declare bankruptcy.\ \ Broward surgeon Leon Doyan, for instance, left \$3.1 million in\ malpractice judgments owed to four former patients when he declared\ bankruptcy in 1995. The state has since revoked Doyan\'s medical\ license. He could not be located for comment.\ \ Fort Lauderdale plastic surgeon Gerard Grau also filed for bankruptcy\ after a patient won a malpractice verdict against him, court records\ show.\ \ Grau, who does not carry malpractice insurance, filed for bankruptcy\ in January. The action came less than two weeks after a Broward County\ jury awarded a \$1.7 million verdict to Grau\'s former patient,\ Plantation Police Lt. Stanley Branham.\ \ Branham claimed that Grau injured a nerve in his right leg during an\ operation to strip varicose veins in May 1988.\ \ Grau said he has been fighting the case, which he considers unjust and\ without merit, through a series of appeals and retrials for nearly a\ decade. He said he is confident he will eventually prevail. \"This is\ not a final judgment until it is final,\" Grau said.\ \ If he exhausts all appeals and still loses, Grau said he would pay the\ court judgment. \"I have always satisfied my responsibilities, legal as\ well as ethical,\" he said.\ \ But Branham\'s attorney, Donald Tompkin, said: \"A doctor holds a\ privileged position in society, and he should be highly accountable to\ each and every one of his or her patients. It\'s socially irresponsible\ and a violation of the Florida statutes not to be financially\ responsible.\"\ \ Board of Medicine attorney Grossman said he believes doctors should\ not be allowed to avoid paying judgments because they are bankrupt.\ \"This is a glaring loophole in the law,\" he said. \"There\'s something\ terribly wrong.\"\ \ Even if doctors do meet financial standards, some relatives of injured\ patients feel the law does not stand up for them.\ \ Under Florida law, family members cannot collect punitive damages for\ death caused by malpractice if their relative is age 25 or over,\ unmarried and has no children.\ \ The law frustrated the family of William Formaad, a 71-year-old\ retired university professor from Pompano Beach who died earlier this\ year following a tummy tuck.\ \ \"The sad thing was that because he had no wife or kids, his value of\ life was practically meaningless under Florida law,\" said Formaad\'s\ niece, Debbie Parrelli, who lives in California. \"It\'s outrageous.\"\ \ Oath forgotten\ \ Even some doctors campaigning for tighter laws over cosmetic surgery\ say there are limits to what government can do to protect the public.\ \ New laws cannot prevent surgeons from making an error in technique or\ using poor judgment, factors that underlie most injuries. Nor can\ stricter statutes prevent some surgeons from taking on patients who\ are poor candidates for cosmetic surgery and thus, more prone to\ injury.\ \ Plantation surgeon Eisenstadt said the public\'s expectations for\ cosmetic operations are often unrealistic and surgeons who try to\ accommodate them can do more harm than good.\ \ \"People come into my office who are the size of a sofa and say they\'ve\ tried every diet and nothing works,\" he said. \"I tell them they\ haven\'t tried the right one. Liposuction won\'t help you.\"\ \ Other doctors worry that competition to attract patients will get\ increasingly intense as more doctors turn to cosmetic surgery to chase\ fast bucks. The median gross income for plastic surgeons was \$449,890\ last year, according to an annual survey published in September by\ Medical Economics magazine.\ \ Four percent of plastic surgeons landed in medicine\'s highest income\ bracket - \$600,000 or more - surpassed only by heart surgeons,\ neurosurgeons and orthopedic surgeons, according to the survey.\ \ Dr. Mark Gorney, a California plastic surgeon and expert on\ complications from liposuction, said the scramble for new business may\ tempt some doctors to go too far by performing longer and riskier\ surgeries to satisfy the whims of patients.\ \ \"This will end badly,\" said Gorney. \"There\'s just too much cash on the\ barrel. When we started out, we were doctors first. One tends to\ forget that you took an oath to first do no harm.\"