Sunday, November 21, 2004
The price of perfection
By Marjory Sherman and Yadira Betances
Cristy Puchtler wasn't looking for magic.
All the plump, young nurse wanted was to firm up her abdomen and breasts after a roller-coaster weight gain and loss that came with having two children. In June, she flew to the Dominican Republic for cut-rate plastic surgery.
"I sort of thought, 'This is a golden opportunity,' " she said. "I've seen all these shows. It's not so much I wanted to be 'The Swan.' I wasn't looking for a miracle; I just wanted something to work with."
Puchtler got a lot more than she bargained for.
She developed a problem that has become chillingly familiar in medical offices in North of Boston communities -- complications from plastic surgery performed in the Dominican.
In scenes being played out from Lawrence to Washington Heights in New York, Dominican plastic surgeons are recruiting Hispanic women at beauty salons, house parties and even on the Internet with the promise of flatter bellies and firmer breasts for bargain prices. Other women are lured by Dominican doctors who agree to operate even though the women are diabetic or obese, decisions that would be frowned upon or banned outright in the United States. Authorities here say that in an atmosphere of different standards of medical care, some not entirely clear to American authorities, a spate of bad infections and one death have surfaced on the Caribbean island.
Last week, Dominican newspapers were filled with stories about a New Jersey woman who died after undergoing liposuction in Santo Domingo.
Maria de los Angeles Morel, 43, a mother of three, died of a blood clot in her lungs within days of undergoing surgery by Dr. Edgar Contreras at the Centro de Bellas Artes (Center of Fine Arts). The district attorney in Santo Domingo is investigating the surgeon, a man who the Diario Libre newspaper reported had a record of 10 patients who died. Authorities suspended Contreras' medical license in 1998 after a patient died of complications following liposuction, but the doctor's credentials were renewed by 1999 when another of his patients died of complications.
"My conscience is clear about this and the other cases," the doctor told Diario Libre. Attempts to reach Contreras by telephone were unsuccessful.
Contreras left the Dominican Republic for Brazil Nov. 13, according to Diario Libre. He was reportedly questioned for six hours by immigration officials before he left.
In one way, Puchtler was lucky. She recovered from her injuries.
A week after she returned home to Lowell after a $3,500 tummy tuck and breast lift in Santo Domingo, an area of skin along the incision line beneath her right breast began to separate and soon expanded to a triangular-shaped hole the size of a quarter, with the stitch inside clearly visible. Sutures that were supposed to dissolve were permanent and they had begun popping through her skin.
It took several office visits to North Andover plastic surgeon Dr. George Chatson to remove the inappropriate suture material from both breasts.
Puchtler and her sister were the first Anglo-Saxon women to undergo surgery at the Dominican clinic, a place she said had a waiting room jammed with Hispanic patients from the United States and the Caribbean. Her sister was pleased with her results, but declined to talk to a news reporter about her experience.
'Lipotourism' on the rise
Blame it on the Fox television show "The Swan" and FX's "Nip and Tuck" or on a celebrity-driven culture that idealizes the Jennifer Lopez body type. Cosmetic surgery has become standard for women of all ages and from all rungs of society. It is no longer the province of well-to-do socialites. Some 8.7 million cosmetic surgeries were performed in 2003 in the United States, one third more than the year before. Thousands more surgeries are performed in the Dominican Republic, primarily on Dominican women who live in the United States, according to Dr. Julio Pena Encarnacio, president of the Dominican Association of Plastic Surgeons.
Women who are pleased with their overseas surgeries are the best advertisement for what has been dubbed by some "lipotourism." Walk down Essex Street in Lawrence, and it's easy to find them. Tiny, dark-eyed beauty Lucy Perez, a hairdresser at Salon 22, had a breast lift and augmentation -- "only two sizes because I'm too skinny." Minerva Fernandez paid $6,000 for a breast reduction and tummy tuck for a "very hangy belly" after three children.
"Everyone I know of who's gone has had a very good experience -- oh, my God, so many people!" she said.
Yet for all the women with good results, a significant minority of others had nips and tucks that did not work out well. A handful had horrendous, even life-threatening, results.
The complication rate for cosmetic surgery is 4 percent in the Dominican Republic, according to that country's Association of Plastic Surgeons. Fewer than 1 percent of U.S. cosmetic surgeries performed in a doctor's office result in serious complications and one case in 51,000 results in death, according to the American Society of Plastic Surgeons. Those numbers are for board-certified plastic surgeons. No survey shows the complications from plastic surgeries performed by all clinicians, board certified or not. In the United States, any doctor with a medical degree can theoretically perform plastic surgery, although most hospitals would ban such procedures.
Several patients each year end up in hospital emergency rooms in Lawrence, Methuen and Salem, Mass., with open wounds and infections after undergoing cosmetic procedures in the Dominican. Another 60 or 70 have been treated in recent years at Greater Lawrence Family Health Center. Another 10 to 20 per year are cared for at Salem Hospital.
Lawrence great-grandmother Ramona Roja, 72, said her infection from a botched tummy tuck and liposuction in 2000 was so advanced that her son rushed her directly from Logan Airport to Holy Family Hospital after she lingered in a near-comatose state for weeks in the Dominican Republic..
"I've seen some significant atrocities," said Dr. Nelson Matos, a family practitioner in Lawrence. "Unfortunately, these women go to get their dream body and they come back with mutilated bodies."
The city of Lawrence, where nearly three-quarters of the residents are Hispanic, is one of the targets of Dominican plastic surgery clinics. Doctors fly in for a day or two to appear at house parties and "information sessions."
"These guys come. They come to New York and to Boston and to Lawrence and they have these parties where they go back with a list of clientele," Matos said.
Patient recruitment common
A ready audience in Lawrence and Latino communities of the North Shore awaits the recruiter.
Lawrence couple Rosa and Luis Polanco, proprietors of the downtown appliance store Luilly Refrigeration, rented a hall on Essex Street in May for friends and customers to listen to Dominican surgeon Dr. Juan Lora, who had operated on both of them -- cosmetic surgery for the wife and post-car accident facial reconstruction for the husband.
A one-hour information session turned into a three-day event, with dozens of people coming from Haverhill, Lawrence, Methuen and as far away as Boston to meet the doctor, and see before and after photographs of women he had operated on.
Rosa Polanco, 35, decided to undergo a tummy tuck and liposuction to slim down her love handles six months after the birth of her second child. The giggly, round-faced mother proudly lifted her shirt to show visitors her back and derriere, now slimmed down with liposuction.
"I don't want to look like J. Lo," she said. "I want to look like me. I want to look pretty for my husband."
"After the last baby -- everyone does it," she laughed as she glanced over her shoulder at her figure in a mirror hung above the rows of refrigerators and washing machines in her store.
In conversations with two- to three-dozen women in downtown Lawrence this summer, The Eagle-Tribune confirmed Polanco's assessment. At every beauty parlor and store, women had either undergone surgeries themselves or they knew of a close friend or relative who had.
U.S. health and medical agencies do not track the numbers of people who seek cosmetic surgery overseas, but Dominican doctor Luis Lopez Tallaj estimated that 95 percent of cosmetic surgery clients in his country are Dominican women who live in the United States. The other 5 percent are Colombian, Chilean and Cuban women living in the United States and women from Puerto Rico. Less than 1 percent are Anglo-Saxon.
Undergoing plastic surgery is especially popular for women in their 20s and 30s who want a breast lift or implants. It is also very common in middle-age and older women who are looking to slim down bellies and bulges with liposuction, tummy tucks and breast reductions. Polanco plans to return to the Dominican Republic for further surgery to remove fat from her upper arms and reduce her breasts.
"Culturally, the ideal body is different. There, it's basically the guitar shape. You want to have curves," said Sandy Almonte, 29, who has four close friends who had work done in the Dominican. "They would go back in a minute."
Plastic surgery is talked about so often in the Hispanic neighborhoods of the Merrimack Valley that the hostess of the daily show "Microfono Abierto" on WCEC radio periodically has a plastic surgeon from the Dominican Republic, Dr. Juan Bautista Lora, on the show. He answers how-to questions and addresses concerns about the botched work of his countrymen.
"I want people to be aware of the risks related to plastic surgery," said radio host Carmen Chalas.
Recruiting is only one way Hispanic women end up on the operating table in the Dominican. Many others decide to undergo the knife after talking about it with friends or relatives.
'I felt like a monster'
Josefina Velasquez, 47, was one of them. Hers is a story of a surgery gone wrong.
The warm and outspoken South Lawrence mother of three decided to have her double chin tightened and the wrinkles beneath her eyes removed last December to surprise her husband and to feel better about herself.
When she looked in the mirror after surgery in Santo Domingo, she was shocked.
"I didn't want anyone to see me. I felt like a monster," she said.
Velasquez was suspicious from the moment she left the crowded waiting room at the Golden Cross Clinic in the northern city of Santiago and was wheeled into the operating room. She said she saw instruments scattered about, ripped sheets on the bed, and doctors chatting on the telephone. She managed to ask whether they sterilized the instruments before the anaesthetic took over.
The surgeon performed far more work than she had requested, adding an eyebrow lift, upper and lower eyelid work, and a face-lift. She hid away for 14 days while she recovered in Santiago, but her incision wounds had become infected.
When she walked in the door of her Lawrence apartment, her family was shocked to see her black and blue face, a deep pocket the size of a pencil eraser gouged beneath her right eye, scalp incisions that were infected, and lumps bulging from her neck that oozed fluid. Her grandson was afraid to go near her. Her daughter took her to the emergency room at Lawrence General Hospital and she later followed up with Matos, the Lawrence doctor.
Since the surgery, her life has been miserable. An ear, nose and throat surgeon drained the lumps in her neck. Her hair fell out in clumps. She developed nerve damage and vision problems. Her eye sockets are two different sizes. To help restore some plumpness to her damaged face, she undergoes Botox and collagen treatments.
"I feel mutilated," Velasquez said. "This won't get fixed until I get another surgery."
The surgeon who operated on Velasquez was Contreras, the same man now being investigated for the death of the New Jersey mother last week.
"I felt horrible when I heard the news, " Velasquez said. "Chills went up and down my spine and I was scared. Then I thank God because he saved me."
"This is no rare occurrence," Matos said of the Velasquez case. "In five years I have seen 20 to 30 cases."
The first botched plastic surgery case he recalled was a woman who went three months after giving birth for liposuction and breast reduction.
"She was so infected that we couldn't get anybody in this community to take care of her," said Matos, who sent her on to a Boston hospital. "She ended up with very deformed breasts, what was left of them."
Another patient of his planned to go to Massachusetts General Hospital for a much-needed breast reduction to ease back pain but decided instead to go to the Dominican Republic. Matos was unaware of the patient's choice until she showed up at his office with a horrific infection.
"It almost looked like a lawn mower had gone over her breasts," Matos said. "Tissue was exposed and it was open and oozing. It was a tough situation. She was in a lot of pain."
Dr. Mona Sigal, acting emergency department director of Salem Hospital, said her staff sees 10 to 20 women each year who develop complications after plastic surgery in the Dominican Republic, a dramatically higher number than the handful of women she has seen in the last eight years who developed infections after surgery in the United States.
Post-surgical infections are typically caused by poor sterilization or ineffective patient education. When women show up at North Shore hospitals with infected plastic surgery wounds, they usually are treated with antibiotics and sent along to plastic surgeons if they need a wound drained or a surgery repaired.
Postoperative problems surface here
Meanwhile, U.S. surgeons who step in to repair work done by others have mixed feelings. While health insurers and MassHealth, the state form of Medicaid, usually cover the cost of minor wound treatment and antibiotics, they often refuse to pay for restoration for a procedure that is not deemed medically necessary, such as cosmetic surgery.
Some plastic surgeons refuse cases, while others ask for private payment or even perform the repair work gratis.
"Plastic surgeons are very embittered having to deal with these after-effects of plastic surgery done in the Dominican Republic," Sigal said. "I've had some plastic surgeons say, 'I'm pretty much fed up with this."'
Chatson, the North Andover plastic surgeon, has no qualms about helping women who return to the United States with postoperative problems. What does concern him are an unprofessional attitude and lack of standards he has encountered in Dominican cases.
"Not once have I ever been contacted prior to seeing the patient by the treating physician, which I think is unprofessional," he said. The improper suture material he has removed represents a standard of care unheard of in the United States. "If you do that, it's going to get infected 100 percent of the time."
Chatson has had to remove an infected breast implant, pull out permanent suture thread, and repair abscesses along the suture line. He has also seen scars from liposuction on the belly that are placed willy-nilly along the abdomen, and not in the typical places such as along the bikini line where scars are easily hidden.
At Greater Lawrence Family Health Center, the city's largest medical provider, doctors have a female patient in her mid-20s who went into shock from an infected breast implant and lost her ability to live independently. She suffered short-term memory loss and total disability. On medicines she cannot afford, with no prospect of work or insurance coverage, she has moved into her mother's home in Lawrence.
Another 38-year-old health center patient needed additional surgery to repair the infections along the incisions from her breast lift and tummy tuck.
"I feel terrible," said clinical director Mary Ioven. "Having surgery anywhere is a risk, and it appears that the risks are greater going out of the country for surgery."
What began as a trickle of injured patients seven or eight years ago has climbed to a steady count, with each of the 74 clinic providers having had at least one case, Ioven said.
The problems made national headlines this summer when the federal Centers for Disease Control warned U.S. doctors to be on the lookout for a nasty bacterial infection that had shown up in a dozen women who had undergone breast lifts, tummy tucks and liposuction in the past two years in the Dominican Republic. A frustrated epidemiologist at the CDC points out that the rules and regulations are not as stringent in the Dominican Republic and that authorities there had declined his agency's offer to send in disease detectives. New York City Health Commissioner Thomas R. Frieden urged people to postpone elective cosmetic surgery in the Dominican Republic.
But plastic surgery errors that require repair or revision are a problem here, as well as in the Dominican. Boston facial surgeon Dr. Ramsey Alsarraf said 25 percent of his work is repairing bad surgeries performed by other doctors.
"I don't think just because you go to the Dominican Republic, you're going to get bad surgery, Alsarraf said. "The bigger thing is people getting surgery in an office (or clinic). It's just so much safer, in my mind, in a hospital where there is an anaesthesiologist and sterile conditions, rather than being sedated in somebody's back room."
But the president of the Dominican College of Medicine, Dr. Waldo Ariel Suero, said news stories of infections in American women are part of "a campaign to smear the plastic surgeons in the Dominican Republic because we are creating competition in the market."
A few doctors in the Dominican Republic say that a handful of physicians in their country has tainted the industry by performing too many surgeries per day, recruiting patients from abroad and sending them home too quickly.
"We have some doctors who have up to 10 patients a day and don't give them enough care," said Dr. Luis Lopez Tallaj of Santiago. "It's a revolving door."
Recruiting patients from abroad is a well-known scenario in the Dominican Republic. Tallaj knows about it and says the practice is flat out against the law.
"I don't agree with this practice. It's illegal," he said.
Higher risk, less accountability
One of the contributing factors, Matos said, is that many women who have health problems, including obesity and diabetes, are still allowed to undergo surgery in the Dominican, putting them at higher risk for problems. He believes that U.S. physicians would be held to a higher standard. He said it is unlikely American doctors would have agreed to work on such cases.
"I have never seen anyone who is thin who has gone for these operations," Matos said. "These are women who are at least moderately obese, the women who go for at least three things -- tummy tuck, breast reduction and liposuction.
"What I see is a quick fix, a quick way of losing 20, 30 pounds. I don't think that plastic surgeons in this country would be operating on these people because obviously they are not candidates for a quick fix," Matos said.
Roja, the Lawrence great-grandmother, spends her days watching soap operas on Telemundo or visiting with her friends in the ValeBrook apartments for the elderly and disabled on Summer Street in Lawrence.
Whatever joy she once had in her life is gone.
"Nada," she said, cutting the air with her hand. Her life is ruined.
Her botched plastic surgery five years ago in the Dominican Republic to remove pounds of fat from her 210-pound frame left her comatose for several days. Even though she is diabetic, she was so impressed with the results of her daughter's liposuction, she saved money and underwent the surgery herself.
The liposuction left her 40 pounds thinner but miserable for life.
She has recovered from the initial phase of a terrible infection that needed to be drained for months, but today, some five years later, she can walk only a few steps before tiring. She doesn't bother to put in her false teeth. Instead of living a vital life, she is restricted to her apartment and a few afternoons each week at adult day care.
"All I do is eat and watch TV. I think about it day and night," she said, sitting with her bare, swollen feet dangling from an easy chair in her tiny living room. "It makes me feel sad. I'd rather have a big belly or die than to be like this."
For Cristy Puchtler, the experience in the Dominican Republic has made her wiser.
She learned to ask questions, plenty of questions, and to do her homework.
She was a little bit concerned when her surgeon refused to perform liposuction on her because she was the first Anglo-Saxon patient he had treated and he worried about the elasticity of her white skin. Puchtler's concerns deepened after she got home and realized that she had been a victim of bad medicine. She calls it negligent.
"I thought about the risks, but my rationale was, there are risks anywhere you go," she said. "If I were to do this again, I would do this in my own country. They're more accountable. I guess you get what you pay for."