Plastic Surgery by a Non-Plastic Surgeon?

Reprinted from The Arizona Republic:



Liposuction deaths: Phoenix area doctor convicted of murder, manslaughter


by Michael Kiefer - Jul. 15, 2011 10:28 PM
The Arizona Republic


An Anthem physician who had three patients die during plastic-surgery procedures in his clinic was found guilty of murder and manslaughter Friday in Maricopa County Superior Court.


Dr. Peter Normann was pronounced guilty of second-degree murder in the deaths of Ralph Gonzalez, 33, of Scottsdale, and Leslie Ann Ray, 53, of California, and of manslaughter for the death of Alicia Santizo Blanco, 41, of Gilbert.


Throughout the trial, which began June 10, Normann's attorneys, John Johnsonand Vikki Liles, maintained that the deaths were accidental, the result of known risks of plastic surgery, and claimed that if Normann, 50, were found guilty, it would mean that all doctors would be liable for procedures gone wrong.




Autopsy findings had listed the deaths as accidental.


But in her closing arguments earlier this week, Deputy County Attorney Jeannette Gallagher said the "combination of incompetence and arrogance in trying to cover up his (Normann's) incompetence led to their deaths."


Gallagher claimed that two of the deaths constituted second-degree murder because of Normann's "extreme indifference to human life," and the third death was manslaughter because of Normann's "conscious disregard of substantial and unjustified risk of death."


After a day and a half of deliberation, the jury came back supporting Gallagher's side of the story.


Normann's friends and family were surprised at the verdict.


"He is not the monster he's been painted to be," said his friend Cindy Jones. "He's a pure, sweet man."


Liles said she and Johnson plan to file a motion for a new trial, claiming that Gallagher had committed perjury in insisting that Normann did not have inventory of a drug that could have saved the lives of one or more of the patients.


Normann had been an emergency-room physician, certified as an internist, and had never done a residency in plastic surgery or anesthesiology.


Gallagher maintained he had undergone six days of training in liposuction and had done some "hands-on training" in liposuction and breast augmentation. He had never done training in fat augmentation, Gallagher said.


Furthermore, she said, his operating room lacked proper oxygen and monitoring equipment, and he worked without anesthesiologists or nurses, relying on a massage therapist and a former restaurant worker with little or no training as medical technicians.


The massage therapist, who assisted in surgery, has already pleaded guilty to eight counts of unlawful practice of medicine and was sentenced last year to five years in prison.


Gonzalez stopped breathing during liposuction in December 2006, due to what Gallagher called a lethal dose of lidocaine, which is used in the procedure. Then, she claimed, Normann mistakenly inserted a breathing tube into Gonzalez's esophagus instead of his trachea, depriving him of oxygen.


When paramedics arrived, they noted that Gonzalez's belly was distended because of the oxygen being pumped into his stomach instead of into his lungs, and they maintained that they tussled with Normann, who insisted on riding in the ambulance and refused to let the EMTs reinsert the tube correctly.


David Duarte, one of the paramedics, told The Republic after the verdict, "He physically was holding onto it, from the get-go."


Duarte threatened to break Normann's arm and then tricked him into letting go of the tube so he could pull it out. Normann insisted on reinserting another.


Duarte said he filed complaints against Normann with the hospital and the state medical board.


Santizo died in April 2007 during multiple procedures, including repositioning a badly placed breast implant, liposuction and an attempt to inject fat into her buttocks to enhance its shape.


During the fat augmentation, Gallagher said, Normann injected the fat directly into a vein, which carried it to her lungs and killed her.


As had occurred during Normann's attempts to resuscitate Gonzalez, Normann was unable to properly insert a breathing tube.


Duarte, coincidentally, was in the hospital when Santizo was brought in, and he filed another complaint.


After the second death, Normann agreed to a voluntary suspension of his medical license and he hired a homeopathic physician, Gary Page, to do liposuction. Gallagher maintained that as a homeopath, Page was not qualified or licensed to perform such procedures.


Ray had traveled from her home in Blythe, Calif., for the surgery in July 2007, which Page performed with no assistance, serving as surgeon, anesthesiologist and monitor.


After the surgery, Page left the clinic, and Ray was left in a recovery room, where later that night, Normann discovered her in respiratory distress because of a reaction to the combination of drugs she had been given. Normann was again unable to insert a breathing tube when she stopped breathing.


Page was charged with manslaughter in Ray's death, but on Friday, he pleaded guilty to the lesser felony charge of endangerment.


Normann will be sentenced Aug. 19 by Judge Paul McMurdie.

Over the past few years, several things have become clear to me about this significant patient safety issue:

1. There are some people who will always knowingly and willingly put themselves at risk if doing so will allow them to save a few dollars... These patients probably cannot be helped.
2. Some physicians are inherently more ethical and moral than others... in other words, and as I have stated many times in the past, the days when it was safe to assume that all doctors were honest professionals with high levels of moral character and integrity are unfortunately over
3. Doctors with questionable ethics, morals, and training are capable of amazing acts of deceit (if not fraud) in order to attract patients and convince them to have surgery.
• The eye doctor here in Orlando who advertises heavily as an expert in liposuction even gives procedures long established in the legitimate plastic surgery community cute, trendy sounding names ("Naturalfill") to make it seem to patients that he is the only one knowledgeable in the technique, and that he has somehow captured magic in a bottle. This violates the code of ethics of the American Society of Plastic Surgeons- but because he is an eye doctor and not a plastic surgeon, he does not have to comply with this important ethical code.
• The same eye doctor advertises himself as "Board Certified", without saying in what or by whom. I believe this is actually a violation of Florida law- but again, no one will do anything about it until and unless there are complaints.
4. The tragic truth (at least so far) has been that when patients are injured or deformed as a result of surgery performed on them by an ER doctor, Eye Doctor (or anyone else without plastic surgery residency training) they almost never complain to the appropriate authorities.
5. Many Central Florida women don't realize that this problem is prevalent in their backyard. In Orlando alone, there are ER doctors, a urologist, and the eye doctor I describe (!) all claiming to be liposuction experts.

These last 2 facts are what I hope to contribute to changing.

I have found that for patients who have experienced the trauma of misplacing trust for their safety and happiness in someone other than a Board Certified Plastic Surgeon, the only thing that they believe could make their situation worse is to have to talk about how they ended up making the poor decisions that lead to their terrible outcome.

I've seen it over and over again in patients who come to see me for correction of problems resulting from surgery performed by local ER doctors and especially the local eye doctor... They want to have their problems corrected, but usually cringe at the notion of having to re-hash the experience as they would have to do if they complained to the authorities with the power to stop these untrained practitioners from practicing plastic surgery. I believe they behave very much like victims of sexual abuse...

Because there is a perceived stigma associated with being "duped" into compromising your safety and appearance, most of these patients won't complain...

But here's the problem... Unless and until patients injured and disfigured complain to authorities, the only way to stop untrained non-plastic surgeons from harming (or indeed killing) more patients is to wait for someone to die- this is the only circumstance that would require the state to investigate without a complaint. 

So unless someone dies, without people affected complaining, these doctors can go on performing procedures they are ill-trained to perform on unsuspecting patients- injuring more of them over time.

Please don't let yourself or someone you love be the victim of doctors practicing outside their training. And if you are, please contact the Florida Board of Medicine.

Awake & In Office Plastic Surgery Procedures

As interest in plastic surgery grows, so do the patient’s options in the various surgical methods and techniques offered by their doctors.  Unfortunately, not all methods are in the patient’s best interest, even when it comes to your anesthesia.  Today, I sat down with Dr. Soto to get a better understanding of why some doctors are apparently disregarding patient safety by promoting awake, in office plastic surgery options for patients. 

Q: “Dr. Soto, I wanted to talk to you about how some patients believe that being awake with local anesthesia for plastic surgery is safer than being under general anesthesia.  What do you tell these patients?”  

A: “Yeah, that’s a really deep and dark pool of water.  Here’s the thing, to really understand this problem you have to understand what’s going on in the overall health care environment.  Most people know that health care is in financial crisis...  For the past 20 years, we have all been hearing about how the cost of health care is going up.  Businesses can’t afford to insure their employees and people are going bankrupt because they can’t afford their healthcare.   

Beginning in the 70’s, one of the things that occurred is that insurance companies turned everything on it’s ear with the establishment of HMOs.  Prior to the formation of these health management organizations or HMO’s, doctors were paid on what was called a fee for service kind of a paradigm.  This meant that whether you wanted a facelift or your gallbladder removed you found a doctor, the doctor billed for the service he or she provided, and you either paid it or your insurance company paid it according to the doctor's fee.  The idea was that doctor's fees would vary with their skill and reputation. Unfortunately, there were some physicians that did take advantage of this system and directly contributed to elevated healthcare costs.

With the formation of HMO’s, the insurance companies basically took over the power and decision making and started cutting doctor’s pay.  That was all done supposedly in order to diminish cost in the healthcare system- which clearly has not occurred. Even a cursory examination of the system would explain why- executives at insurance companies are making huge salaries, and paying themselves astronomical bonuses, with hospitals charging $200 for a single dose of aspirin- and blaming doctors for the ongoing increases in costs even as the reimbursement to physicians goes down.
Combine this with the well-understood toll taken on the profession and the environment by the wild-west medical malpractice culture, and understanding how costs are so high is not difficult.

“Over the period in question, the cost of healthcare has continued to increase astronomically while insurance company executives have increased their income many fold.  Some of these guys are making bonuses in the multiple millions of dollars annually.  So while the overall cost of healthcare has not gone down, what has gone down is the compensation to physicians.  Relative to the overall inflation rate and the cost of living, the average doctor who bases their practice on taking care of insured patients has experienced a significant decline in their income and in their lifestyle.  Most doctors still make a pretty good living, so should we really feel sorry for them?  It’s hard for us, as an average person, to feel sorry for people who are still making a pretty good income.”

“On the other hand, we need to remember that the average physician has worked very hard over a period of 15-20 years to become a well trained and educated, responsible physician.  Most people who have gone to school for that long and have trained for that long expect there to be a reward at some point.  If you went to college and worked hard, and then you went to medical school and worked hard to receive the best education you could, and then did residency training, and at the end of all that the investment and hard work somebody tells you that insurance companies and the government are going to cut your pay and you are going to make less and less money and need to see more and more patients, all while constantly suffering the threat of (often) frivolous malpractice suits, it becomes really difficult to not feel frustrated and cheated.  

What this has caused is an environment where we have lots and lots of disaffected and frustrated doctors in the United States.  

People who have spent years and years learning and training in ways to take good care of people really are not that interested in taking care of people anymore because they don’t feel well compensated.  When you combine that with the fact that most people in the country, including all of these unhappy and frustrated doctors, know that insurance and the government don’t pay for cosmetic surgery, the leap form being a trained family practice doctor, a trained gynecologist or even as we have here in Orlando - an eye doctor wanting to do plastic surgery in order to make more money - is not that big of a leap.  And so what has happened, unfortunately, is that a lot of these frustrated and unhappy doctors have decided that even though they are not trained to do it, they are going to start doing some cosmetic surgery.  This way they can cut the insurance company and the government out of the loop, increase the amount of money that they make, work less hard, and overall have a better lifestyle - the lifestyle they felt they were promised when they first went to medical school.”  

“So on the one hand, is it fair to completely blame the doctors who are irresponsibly performing plastic surgery without plastic surgery training?  My personal belief is yes, it is.  

But some people would argue no, and some people would argue that the responsibility rests on all of society.  

We created this environment; therefore, we shouldn’t blame these doctors who in response to the environment we created are doing these things.  

On the other hand, doctors are smart people - they wouldn’t be doctors if they weren’t.  All of us are supposed to be ethical people too.  At some level, all of these people who are performing plastic surgery without plastic surgery training know that what they are doing is wrong.  They are doing it because they want to make more money.  I have no problem with somebody finishing their training as an eye doctor, an ophthalmologist, such as Dr. Roger Bassin here in town, who then decided that they really wanted to be a plastic surgeon.  But if you finish your training for ophthalmology and decide you want to be a plastic surgeon, do it right.  Be honest.  Go back and get training in plastic surgery.  Then you can hang out your shingle and call yourself a plastic surgeon - honestly and ethically.  I do have a problem with people finishing training in ophthalmology or in ER medicine.  These people are ER doctors and they want to do cosmetic surgery?  I think that’s unethical.  I think it’s also irresponsible, and I think it’s bordering on fraud.  I think they do deserve to be held responsible when things don’t go well because they aren’t trained to do the cosmetic surgery that they are doing.  Hopefully, at least with that explanation we can all understand why they are doing it.  I think it’s wrong, unethical, irresponsible and it ought to be illegal, but I think that those are the reasons why they are doing what they do.”

“Understanding that there are these people who are not trained in plastic surgery wanting to do plastic surgery, we have to understand what they need to do in order to accomplish that.  One of the things in the United States that has always limited what a doctor could do, is the hospital credentialing process.  

In other words, I am a board certified plastic surgeon and I have every credential a plastic surgeon could have, but what if one day I decided I wanted to do heart surgery?  What if I thought those heart surgeons are making a lot of money.  Maybe I would like to do some heart surgery and make some more money myself.  What’s to keep me from doing that?   

Well traditionally, what has been in place to limit doctor’s practices is hospitals.  

In the past, you couldn’t get permission to do an operation in a hospital unless you could prove to the hospital’s credentialing committee that you had legitimate training in that procedure.   So when I apply for privileges at any hospital they ask me in written form what operations I want to do there, and then they make me produce proof that I have been trained to do those operations.  They then decide if they are going to give me permission to do those operations in the hospital or not.  So if one day I decided that I wanted to do heart surgery and I found a nice patient who was willing to let me do heart surgery on her, what would stop me from actually completing that irresponsible plan is that the hospital would never give me permission to do it.  They would say, ‘Dr. Soto you are a plastic surgeon.  You can’t be doing heart surgery.  I don’t care if the patient is willing to let you do it and I don’t care if you want to do it.  You are not trained in heart surgery, so we are not going to let you do it.’ ”

“Well unfortunately, there’s nothing to keep doctors from doing whatever they want if they can do it in their office.  If you have this eye doctor, or if you have an ER doctor or a gynecologist, and they are willing and able to convince a nice patient that they are able to do a tummy tuck on them in their office (because as I said they would never be able to get permission to do it in a hospital), there’s nothing to stop them.  There’s no law that says gynecologists can’t do tummy tucks, or heart surgery for that matter, if they can do it in their office on a patient who is willing to let them do it.

So how do you do these things in the office if you don’t have a board certified anesthesiologists and you don’t have a certified operating room to do it in?  Well you have to somehow convince people that doing this operation under local anesthesia is the right way to go.  

In the office, under local anesthesia, you don’t need an anesthesiologist, you don’t need an accredited operating room, and you definitely don’t need the permission of a bunch of other doctors and hospital administrators.  

So, over the past few years, we’ve seen a number of all types of doctors who are not plastic surgeons telling their patients that general anesthesia is dangerous and local anesthesia is much safer.  ‘Why don’t you let me do your cosmetic surgery.  We’ll do it right here in the comfort and convenience of my office.  You won’t be subjected to the risks of general anesthesia.’  And they scare them by talking about dying, heart attacks and such.  They tell them it’s much safer in their office and much easier.  ‘You’ll have local anesthesia and you can go home the same day.’ ” 

“Well here’s the thing - First of all, they are being disingenuous.  If doing things like tummy tucks and breast augmentations were safer under local anesthesia, every board certified plastic surgeon in the country would be doing it that way too.  The truth is it is not safer to do it that way.  Those things introduce a lot of risks that the average patient wouldn’t take if they knew they were taking them.  

The fact is is that general anesthesia is a much safer way to perform these operations.  And the fact is that the vast majority of patients who have unfortunately died during cosmetic plastic surgery over the past 5-10 years nationally have died as a result of excess or toxic levels of local anesthesia.  Most of the time, the doctors offering local anesthesia for awake plastic surgery do not share that fact with their patients.  They also don’t tell them that they are not plastic surgeons and they are really eye doctors, but I guess we already covered that.”

“So the fact is, awake plastic surgery is really not something you should consider, unless you are thinking about a minor procedure.  If you are talking about having a tooth removed or maybe even a little eyelid surgery where the area of the operation is a very small area and you are only going to get a little bit of local anesthesia, that is really not a problem.  I do those things myself here in my office.  But if we are talking about a large operation where you are going to be manipulating muscles and putting implants in and doing things of that nature, that simply can’t be done safely, effectively, or ethically, in my opinion, on an awake patient under local anesthesia.”

Survey of America's Most Experienced Plastic Surgeons Confirms Many Newer Liposuction Devices are Marketing Gimmicks

This piece, summarizing the findings of a recent peer-reviewed article in one of our specialty's major journals, makes all of the points I've been writing about for some time now... With regard to ANY new technology (especially where your safety and happiness may be at stake), the appropriate questions to ask before allowing it to be used on you are:

• Is it BETTER than existing alternatives- that is, is it going to be more likely to help me and my surgeon achieve my goals?
• Is it SAFER than existing alternatives?
• Is it LESS EXPENSIVE than existing alternatives? Bear in mind that this is only important if the answers to the first two questions are "yes".

From The American Society for Aesthetic Plastic Surgery:

Survey Extracts Surgeons’ Preferences on Liposuction

Results published in the February Issue of the Aesthetic Surgery Journal

New York, NY (February 14, 2011)– 

With an array of new innovations in liposuction and other forms of fat removal, which do plastic surgeons prefer, and which do they perceive as the safest? 

To answer these questions, the American Society for Aesthetic Plastic Surgery (ASAPS) recently conducted a survey of its membership to uncover their experience with liposuction, new fat removal technologies and the management of complications.  

The survey revealed that suction-assisted lipectomy (SAL), or “traditional” liposuction, was the preferred method of fat removal for over half of respondents; power-assisted liposuction (PAL) and ultrasound-assisted liposuction (UAL) were also popular. Laser-assisted liposuction (LAL) and external noninvasive devices, such as external ultrasound and laser, were the least popular methods for fat removal.  The full results of the ASAPS Current Trends in Liposuction Survey have been published in the February issue of the Aesthetic Surgery Journal (ASJ).

“In a field that is so rapidly advancing, it is essential to continually evaluate new technologies and methods to ensure that we maintain the safety of our patients,” said Jamil Ahmad, MD, lead author of the survey, “Our survey found that ASAPS members tend to more frequently employ the fat removal methods that have the longest track records and the most data to support their efficacy and safety. In the future, we may notice preferences shift as we see additional prospective data comparing techniques, and as we gain more experience with newer methods. These factors will also help us continue to improve safety-related standards of care.”

The Aesthetic Society survey consisted of 17 questions pertaining to the application of liposuction and other fat removal techniques, management of complications, and experience with newer fat removal technologies. The survey was distributed via email to 1,713 ASAPS members, of whom 492 (28.7 percent) responded. Highlights of the survey include the following findings:

Most respondents perform between 51 and 100 liposuctions per year.

Most currently employ or have previous experience with SAL (92.7 percent), UAL (59.6 percent), and PAL (44.7 percent). Fewer have experience with LAL (12.8 percent), mesotherapy (5.7 percent), or noninvasive devices (12.8 percent).

The preferred method of fat removal from most to least popular was:

SAL (51.4 percent)

PAL (23.0 percent)

UAL (20.9 percent)

LAL (3.9 percent)

Noninvasive devices (0.8 percent)

Respondents felt that newer fat removal technologies including LAL and mesotherapy were associated with a disproportionately higher rate of complications compared with more established methods (ie., SAL, PAL, and UAL). (emphasis added)

Respondents felt that marketing (68.3 percent) was the most common reason that influenced patients to choose newer treatments such as LAL. (emphasis added)

Members support education of physicians with appropriate aesthetic surgery training and similar ethical practice but are concerned with industry marketing to physicians without appropriate aesthetic surgery training, practicing outside of their scope of practice. (for example, the Orlando area eye doctor who heavily markets Naturalfill and Aqualipo)

“Evaluating the opinions of our members is an excellent way to identify industry trends and determine how to improve the field for both surgeons and patients,” said Felmont Eaves III, MD, ASAPS president.   “It is important for us to conduct surveys such as these, not only regarding liposuction and other forms of fat removal, but for all facets of aesthetic surgery.”

Liposuction, also called lipoplasty, removes deposits of excess fat from specific areas of the body including the face and neck. It is the second most popular surgical cosmetic procedure in the U.S., with 283,735 liposuction surgeries performed in the U.S. in 2009, according to ASAPS.

About ASJ

The Aesthetic Surgery Journal is the peer-reviewed publication of the American Society for Aesthetic Plastic Surgery (ASAPS) and is the most widely read clinical journal in the field of cosmetic surgery, with subscribers in more than 60 countries.

About ASAPS

The American Society for Aesthetic Plastic Surgery (ASAPS), is recognized as the world’s leading organization devoted entirely to aesthetic plastic surgery and cosmetic medicine of the face and body.  ASAPS is comprised of over 2,600 Plastic Surgeons; active members are certified by the American Board of Plastic Surgery (USA) or by the Royal College of Physicians and Surgeons of Canada and have extensive training in the complete spectrum of surgical and non-surgical aesthetic procedures. International active members are certified by equivalent boards of their respective countries. All members worldwide adhere to a strict Code of Ethics and must meet stringent membership requirements.

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