Found 76 Results Sorted by Case Date
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Florida – Plastic Surgery – Excessive Use Of Lidocaine During SmartLipo Results In Severe Complications



On 11/2/2012, a 39-year-old female presented to an internist for skin tightening intervention in the lower abdomen under local anesthesia with mild oral and intramuscular sedation, a procedure commonly known as “smart lipo.”

The patient was given 700 to 800 ml of an IV of various medicines, including lidocaine, and then three injections of 1% lidocaine.

Shortly after administration of the IV of various medicines and the lidocaine shots, the patient began to have a grand mal seizure.  The internist treated the patient with IV fluids and Narcan.

The patient reportedly had normal vital signs at the time, but then had another seizure fifteen minutes later.

According to the internist, ten minutes later, on the third seizure, the internist requested an ambulance.

The internist indicated that the patient, upon the third seizure, lost all pulse and respiration.

According to the EMS staff, the internist did not recognize that the patient was in cardiac arrest upon EMS arrival and was not assisting the patient.

The patient was taken to the emergency room in full cardiac arrest, where she died.

The medical examiner listed the patient’s cause of death as acute lidocaine toxicity due to use of lidocaine in a medical procedure.

The internist failed to adequately prepare or maintain medical records in this case in a way that allowed any medical professionals to adequately know the amount of lidocaine administered to the patient.

The Medical Board of Florida judged the internist’s conduct to be below the minimal standard of competence given that he failed to recognize a lack of blood pressure and administer cardiac support (CPR) upon recognition of a lack of blood pressure.  The internist also administered excess lidocaine that caused the patient’s death due to lidocaine toxicity.

The Medical Board of Florida issued a reprimand against the internist’s license.  The Medical Board of Florida ordered that the internist pay of $5,000 for his license and pay reimbursement costs for the case at a minimum of $10,683.65 and not to exceed $12,683.65.  The Medical Board of Florida ordered that the internist complete a records course, complete ten hours of continuing medical education in liposuction procedures and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: August 2017


Specialty: Plastic Surgery, Internal Medicine


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Post-operative/Operative Complication


Medical Error: Improper medication management, Underestimation of likelihood or severity, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Plastic Surgery – Failure To Manage Hypertension And Hypoxia Perioperatively



In 2013, Plastic Surgeon B was an independent contractor providing facial cosmetic surgery services two days a week for a clinic in California.  A 57-year-old male made an appointment at the clinic for 9/7/2013.  The patient was interested in improving the appearance of his lower face and eyes.

The patient filled out a medical history form, on which he checked, “Yes” to the question, “Are you currently undergoing radiation therapy or chemotherapy for cancer?”  There was no additional explanation.  He did not list the name of the primary care physician (PCP) on the form but indicated that his PCP could be contacted for questions.  He indicated that he was taking no medications and had no allergies.  He listed no prior surgeries.

On 9/13/2013, the patient met with Plastic Surgeon A for a pre-operative visit.  Plastic Surgeon A performed a history and physical examination and wrote prescriptions for diazepam 5 mg #20 tablets, Tylenol with oxycodone 10/325 mg #30, and Keflex 500 mg.  Plastic Surgeon A indicated that the patient had hypertension but was not on any medication.  The patient’s blood pressure was noted to be 152/97.  The patient signed informed consent forms for a face and neck-firming procedure as well as blepharoplasty.  Plastic Surgeon A did not co-sign the forms (which are used to indicate that the plastic surgeon had personally reviewed the risks, benefits, and alternatives of the procedures with the patient and answered all questions).  Plastic Surgeon A noted his surgical plan as “Face & neck.  Upper lids skin only.  Possible fat transfer to cheeks.  Fast absorbing suture.”  Plastic Surgeon A did not sign his surgical plan.

Plastic Surgeon A left his position at the clinic, and the patient’s care was transferred to Plastic Surgeon B.  Surgery was rescheduled for 9/26/2013 with Plastic Surgeon B, and a “Meet the Doctor” date of 9/19/2013 was scheduled.  On 9/16/2013, Plastic Surgeon B filled out and signed a History and Physician Examination form on the patient.  The form documented only the facial examination and surgical plan, including lower lid laser.  There is no documentation of vital signs, particularly no blood pressure reading.  The patient signed new informed consent forms for face and neck firming surgery and blepharoplasty by Plastic Surgeon B.  Plastic Surgeon B did not co-sign the informed consent forms indicating that he had personally reviewed the risks, benefits, and alternatives of the procedures with the patient and answered all questions.  There is no consent form for laser resurfacing.

On 9/25/2013, the patient saw Plastic Surgeon B, and Plastic Surgeon B’s notes indicate “Famvir” and “take BP today.”  There is no documentation in the chart that a prescription for Famvir was written or that the drug was dispensed or used by the patient.  There is also no documentation that the patient’s blood pressure was taken.

The patient presented for surgery on 9/26/2013.  Vital signs were taken, and his blood pressure was documented as 177/116 right and 160/95 left.  At 11:30 a.m., the patient was in the surgical suite and was given oral sedation consisting of diazepam 30 mg; lorazepam 1 mg; acetaminophen with hydrocodone 5/325 mg; promethazine 25 mg; clonidine 0.1 mg; and diphenhydramine 25 mg.  Local anesthesia was infiltrated into the facial skin and subcutaneous tissues one hour and fifteen minutes later at 12:45 p.m.  This consisted of 1% lidocaine with 1:100,000 epinephrine (75 ml); 0.25% bupivacaine with 1:200,000 epinephrine (30 ml); normal saline (60 ml); and approximately 1:150,000 epinephrine with the total being approximately 200 ml of local anesthesia infiltrated.

Surgery commenced sometime after 1:00 p.m. on 9/26/2013.  The patient’s pulse rate, oxygen saturation, and blood pressure were monitored automatically throughout the procedure.  The patient remained hypertensive throughout the procedure, and no additional medications were provided for blood pressure control.  The procedure began with the patient’s oxygen saturation at 98%.  At 1:32 p.m., the oxygen saturation dropped to 58% and remained in the 60-70% range until approximately 3:15 p.m., when it returned to the 90% range.  Additional sedating drugs were given between 4:05 p.m. and 4:30 p.m., and oxygen readings fell again into the 50-70% range until the end of the procedure with only occasional readings in the normal range.

Although not documented in the record, Plastic Surgeon B indicated that sometime after 3:00 p.m., he was called upon to attend a post-operative patient who had presented with incisions on her face that had opened, an emergency.  Plastic Surgeon B left the patient in the surgical suite and, after 20 to 30 minutes attending to the emergency patient, Plastic Surgeon B returned to the surgical suite to complete the patient’s surgery.  Neither his departure from the OR nor the names and qualifications of those attending the patient in his absence are documented in the operative note.  Upon Plastic Surgeon B’s return, the patient was given additional oral sedation, as well as more local anesthesia.  The time of injection of an additional 44 ml of local anesthesia was not documented on the Patient Surgery Information Sheet.  The certified surgical technician administered the anesthesia under Plastic Surgeon B’s supervision and assisted in the procedure; Plastic Surgeon B indicated at his subject interview with the Board on 7/30/2015 that a nurse was also present, but this is not documented in the record.  Surgery was completed at approximately 6:00 p.m.  The patient’s final blood pressure was 186/116.  The patient was discharged home at 6:25 p.m.

The operative report on the patient signed by Plastic Surgeon B is a template document that provided no personal detail on the procedure.  For example, the template stated that skin openings were left behind the patient’s ears for expressing fluid, but the post-operative notes stated that the patient had drainage tubes placed bilaterally.  The operative report stated that a lower lid blepharoplasty was performed, but no such procedure was performed on the patient.

Post-operative photographs of the patient were taken on 9/27/2013, but there is no progress note for this visit.  A note for a visit on 9/28/2013 was signed by a technician and noted that the drainage tubes were being left in place; the patient was apparently not seen by a physician on this visit.  On 9/30/2013, the patient was examined by Plastic Surgeon B (although he did not sign the progress note); at this time, the remaining drainage tube was removed; the patient’s blood pressure was recorded as 187/113; advice given to the patient was to rest and relax.  On 10/2/2013, the patient was seen by staff, and his eyelid sutures were removed; the patient’s blood pressure was recorded as 154/94.  On 10/5/2013, the patient’s blood pressure was recorded as 162/105; there is no progress note for this visit, except that an unsigned addendum to the 10/2/2013 visit indicates that the facelift sutures were removed on 10/5/2013.  Post-operative photographs were taken on 10/21/2013, but there is no accompanying progress note.

The patient was dissatisfied with the results of the procedure and the care he received from Plastic Surgeon B.  The patient filed a consumer complaint, which the Board received on 6/23/2014.

The Board judged Plastic Surgeon B’s conduct to be below the minimum level of competence given failure to address the patient’s hypertension, failure to sufficiently address the patient’s episodes of hypoxia during the procedure, and failure to accurately document his encounters with the patient.

The Board notes that performing surgery on a hypertensive patient adds additional risk to the procedure for excessive bleeding, hematoma formation, and stroke.  Such a risk should be mitigated prior to the initiation of any elective procedure.  Per the Board, if a patient becomes hypertensive during a surgical procedure, medications should be provided to the patient to stabilize the blood pressure.

The Board also notes that if a patient becomes hypoxic during a procedure, it is required to assure the oxygen saturation probe is working correctly and to provide exogenous oxygen for the patient to breathe and return his oxygen saturation to the normal range.  There is no documentation that Plastic Surgeon B responded to the patient’s low oxygen saturation.

The Board expressed concern that the patient’s medical record contained numerous instances of unsigned, incomplete, and absent notes.  Vital signs were at times not documented.  A prescription for Famvir was administered but not documented.  There was no documentation of Plastic Surgeon B’s absence from the surgical suite and no indication of personnel that was left in charge of the patient while Plastic Surgeon B addressed another patient’s emergency.  Operative notes were inadequate and inaccurate.

The Board issued a public reprimand with stipulations that Plastic Surgeon B a medical record keeping course and a continuing medical education course in pre-operative patient evaluation, informed consent, and management of intra-operative hypertension and hypoxia.

State: California


Date: August 2017


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Improper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Plastic Surgery – Liposuction Performed On A Patient With Obesity, Diabetes, Hypertension, Asthma, And Human Immunodeficiency Virus



On 1/11/2013, a 50-year-old male presented to a plastic surgeon and underwent liposuction of his chin, upper abdomen, lower abdomen, upper back, and lower back/flanks.

The patient’s medical history included obesity, diabetes, hypertension, asthma, and human immunodeficiency virus (HIV) positive status.

Due to his medical history, the patient was at high risk of complications from the liposuction procedure.

Due to the high risk of complications, the patient was not a candidate for liposuction surgery.

During the liposuction procedure, the plastic surgeon injected tumescent wetting solution into the patient.  The tumescent liposuction technique, as opposed to “dry liposuction,” involves injection of tumescent wetting solution into a patient’s fatty deposits to reduce the amount of blood lost during the procedure.

The standard concentration of tumescent wetting solution used for liposuction is approximately one part epinephrine per 1 million units.  The tumescent wetting solution that the patient injected into the patient did not contain any epinephrine.

During the liposuction procedure, the plastic surgeon perforated the patient’s abdominal cavity and bowel.

On 1/16/2013, the patient presented to the medical center emergency department with complaints of abdominal pain, nausea, and vomiting.

Evaluation revealed that the patient was septic, in acute renal failure, and had free air in his abdomen.

The patient underwent emergent exploratory laparotomy which revealed multiple small bowel perforations, peritonitis, a mesenteric tear, pelvic abscess, and necrotizing fasciitis on the anterior abdominal wall.

The patient underwent release of a small bowel obstruction, small bowel resection, repair of the mesenteric defect, drainage of the pelvic abscess, and radical debridement of the necrotizing fasciitis.

The Medical Board of Florida judged that the plastic surgeon failed to avoid performing the liposuction procedure due to the high risk of complications posed by his medical history.  He failed to use epinephrine in the tumescent wetting solution used for the liposuction procedure.  He also failed to avoid perforating the abdominal cavity and bowel.

The Medical Board of Florida issued a letter of concern against the plastic surgeon’s license.  The Medical Board of Florida ordered that the plastic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $3,090.60 but not to exceed $5,090.60.  The Medical Board of Florida also ordered that the plastic surgeon complete five hours of continuing medical education in the area of “Tumescent Liposuction” and five hours of continuing medical education in “risk management.”

State: Florida


Date: May 2017


Specialty: Plastic Surgery


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Procedural Site Infection, Acute Abdomen, Necrotizing Fasciitis, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Improper medication management, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Plastic Surgery – Laser Treatment For Lipoma At The Back Of The Head



On 9/6/2011, a 51-year-old male consulted with a family practitioner performing cosmetic procedures for the removal of a lipoma located at the back of his head.  The patient’s history included hyperthyroidism, for which he was seeing a physician, and atrial fibrillation, for which the patient chose not to take blood thinners.  The family practitioner’s assessment and plan was “LipoLite of lipoma of occiput.”  The patient signed a consent form.  However, there was no mention of the potential for a burn pertaining to the type of laser used by the family practitioner.  In addition, there was no verbal discussion of potential risks and complications.

On 9/9/2011, the patient returned to the family practitioner for LipoLite removal of the lipoma.  The only documentation in the medical record of the visit is a procedure note.  There are no vital signs recorded in the procedure note, no indication of the number of joules, or energy that was delivered, and no mention of temperature monitoring.  There are start and end times for the infiltration of lidocaine with epinephrine and a start and end time indicating a 15 minute treatment with LipoLite laser with 2.5 zones treated.  The family practitioner noted sloughing of the skin at the left upper part of the lipoma near an old scar and the epithelium is noted to have a slight blister formation.  The family practitioner monitored tissue temperature with his hand and by the patient’s reaction to various levels of pain.

On 9/14/2011, the family practitioner noted mild edema and erythema of the site and surrounding area.  On 9/19/2011, there was drainage from the wound and the family practitioner noted the central area with a dark firm scabbed layer with pink erythema at the lower left with no abscess or seroma and mild tenderness.  On 9/28/2011, the patient returned reporting that the wound had been leaking for approximately five days.  The patient was continued on wound care.

On 10/5/2011, the patient noted a hard scabbed area with a surrounding white area.  The family practitioner referred the patient to a wound care clinic.

The Board deemed the family practitioner’s conduct as having fallen below the standard of care for failing to perform a history and physical examination at the initial consultation, for failing to record vital signs before and during a surgical procedure, and for failing to obtain sufficient knowledge of the laser prior to use.  The Board noted a failure to recognize a blister during a laser procedure and a scab or eschar in the post-operative period as representing a possible full-thickness skin loss as well as failure to obtain cultures from a draining wound.

The Board issued a public reprimand against the physician.  Stipulations included 30 hours of continuing medical education in the area of cosmetic laser surgery and a continuing medical education course in medical record keeping.

State: California


Date: May 2017


Specialty: Plastic Surgery, Dermatology, Family Medicine


Symptom: Mass (Breast Mass, Lump, etc.), Dermatological Abnormality, Wound Drainage


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Internal Medicine – Complaints Of Larger Than Expected Male Breasts Despite Smart-Lipo On Chin, Chest, And Abdomen



On 4/12/2011, a 60-year-old male (6’ tall and 239 pounds) went to Internist A for a consultation for Smart-Lipo to his chin, male chest, and abdomen.  The patient had previously undergone liposuction procedures by other providers, but the specific body regions were not noted in the medical record. At this consultation, the patient did not meet with Internist A.  A Smart-Lipo surgery was scheduled with Internist A 2 days later on 4/14/2011.

On 4/14/2011, the patient arrived for surgery.  During the pre-operative appointment, the patient met with a member of Internist A’s staff.  Internist A did not meet with the patient in person until immediately before the procedure. The “Patient Evaluation” form indicated that the patient took aspirin one week before.

During the procedure, Internist A stopped the procedure to the patient’s chin because of excessive bleeding.  In the patient’s medical record, the “Operative Summary” contained a pre-written paragraph detailing the procedure.  The summary stated that “Patient tolerated procedure well with no complications” despite the fact that there were complications, and Internist A did not complete the procedure as planned.  Below the pre-printed portion of the “Operative Summary,” there was a handwritten note from Internist A that was difficult to read. The note stated that there was increased bleeding to the patient’s chin, and the procedure was stopped.  The note also stated that the patient may need additional surgery. The patient never saw Internist A after the Smart-Lipo procedure.

On 4/15/2011, the patient had his follow-up appointment with Internist B.  The patient complained of bruising to his left breast, that his breasts were still larger than he expected, and that Internist A only completed half of the chin procedure.  According to the patient, Internist B told him that Internist A should never have operated on him because he was not a good candidate due to gynecomastia. On the “1-3 Day Follow Up Report” form, there was a note about what advice Internist B gave the patient, but the note was not legible.

The patient’s medical record included a handwritten note (the date of the note was not legible) that the patient called Internist A’s office requesting a refund.  The note stated that the patient was upset because the ad for Internist A’s clinic and the Smart-Lipo procedure promised that he would be back to work the following day following “the minimally invasive procedure,” but he was not able to return to work for 3 weeks.  He further complained that he did not meet with Internist A until the surgery and did not have sufficient time between the pre-operative appointment and the actual surgery (both on the same day). The patient refused to go back to Internist A’s clinic for follow-up appointments.  Internist A refunded the patient $2,400 out of the $7,200 paid. The patient received post-operative care from other physicians.

During Internist A’s Board interview on 12/9/2014, she was asked about the advertising relied on by the patient.  Internist A stated that she was not in charge of marketing despite being the owner and medical director of the center.

The Medical Board of California judged that Internist A’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records, recognize the signs and symptoms of gynecomastia as a possible source of the patient’s enlarged breast tissue, complete a medical evaluation, and conduct a thorough pre-operative evaluation of the patient.  Internist A also lacked sufficient skills and knowledge to perform Smart-Lipo safely.

For this case and others, the Medical Board of California placed Internist A on probation for 4 years and ordered Internist A to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for eat year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  Internist A was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. Internist A was also prohibited from supervising physician assistants.

State: California


Date: April 2017


Specialty: Internal Medicine, Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Internal Medicine – Smart-Lipo Planned For Seven Regions Of An Obese Woman’s Body



On 4/30/2013, a 54-year-old female (5’6” tall weighing approximately 210 pounds) went to a clinic for a consultation with an internist.  The patient was interested in Smart-Lipo to her chin/neck/jowls, front and back bra rolls, upper arms, inner and outer thighs, hips, waist/abdomen, knees, and pubic regions.  The patient indicated that she had previously undergone a “tummy tuck with liposuction.” The medical record did not indicate when she underwent this procedure. The patient also indicated that she suffered from diabetes and took aspirin regularly.  Smart-Lipo surgery was scheduled for 5/31/2013, and the patient paid for the surgery to be performed on the 7 areas initially requested.

That same day, the patient underwent her pre-operative procedures and testing, which included blood work, an incomplete history, and an extremely limited physical examination conducted by a Licensed Vocational Nurse (LVN).  The patient completed a two page “Medical Intake” form, a one page medication list, and a written consent form specifically for patients with a high body mass index. The LVN also completed a 2 page “Pre-Procedural Evaluation for Smart-Lipo” form that involved checking boxes and filling in blanks for vital signs and what areas would benefit from Smart-Lipo procedure.  The patient did not meet with the internist until the day of surgery.

On 5/31/2013, the internist only performed Smart-Lipo on the patient’s chin/neck, upper and lower abdomen, and pubic areas, rather than all 7 areas scheduled.  The medical records did not clearly indicate what areas the internist operated on as all seven areas were circled on a “Body Regions” form. According to the patient, when the internist first came into the surgery room, she asked the patient what procedures she was having done.  The patient told the internist “it says in the file.” The internist and her assistant then had to locate the medical file. The patient’s medical records did not include an operative report or summary written by the internist about the procedure. The records did not indicate why only 5 of the 7 areas scheduled were operated on.

The patient complained that she was in severe pain throughout the entire procedure and requested multiple times that the internist stop.  According to the patient, the internist told her this was the price of beauty and continued with the procedure. During the internist’s interview with the Medical Board on 12/9/2014, the internist did not remember if the patient complained about being in pain during the procedure, but the “Physician Charting” form indicated that the patient’s pain level was between a 6 and a 10 out of 10.  There was also a notation in the chart that when the patient complained about the 10 out of 10 pain, she was laughing. The internist said she would have stopped the procedure if the patient asked for it to be stopped and if “I thought that she was actually in pain.”

On 6/3/2013, the patient returned to the internist’s clinic for post-surgical follow-up.  During this appointment, the patient indicated that she was not sure whether she was happy with the results, that she was in pain, she was dizzy, and that she had “light bruising” to her abdomen.  The patient also noted that she had a lot of post-surgery drainage requiring her to change the bandages several times.

On 9/16/2013, the internist conducted a follow-up on the patient’s upper arms, upper abdomen, and pubic region.  The “Six-Month Follow-Up Report” indicated that the patient was still suffering from pain and was not happy with the results.  The patient wanted the internist to fix the areas that she was unhappy with, but the report did not specify if those were all the regions where the Smart-Lipo was performed or just on some of the areas.

On 11/16/2013, the patient saw the internist for the last follow-up.  During this appointment, the medical note indicated that the patient refused to allow any measurements or her weight to be taken and remained unhappy with the results.  According to the note, the patient wanted her arms to “look like [the internist’s]” and was promised that another doctor could do that. The note further stated “it is impossible to make her arms look absolutely perfect.”

During the internist’s interview with the Medical Board, she indicated that she offered to do a revision on the patient’s arms, but could not promise to make her arms look perfect.  The internist claimed that the patient rejected the revision surgery. There was no notation in the file that the internist offered the patient a revision surgery to try to correct the problems that the patient noted.  The internist refunded the patient for 2 of the 7 regions paid for that were not operated on.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records and lacked sufficient skills and knowledge to perform Smart-Lipo safely.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California


Date: April 2017


Specialty: Internal Medicine, Plastic Surgery


Symptom: Dizziness, Pain, Wound Drainage


Diagnosis: N/A


Medical Error: Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Internal Medicine – Smart-Lipo For Enlarged Male Chest Results In Asymmetry



On 3/9/2013, a 63-year-old male (6’2” tall who weighed 244.5 pounds) went to an internist’s clinic for a Smart-Lipo consultation for his enlarged male chest.  On the “Pre-Procedural Evaluation for Smart-Lipo” form, the consultant noted that the patient could benefit from Smart-Lipo to the waist, male chest, and lower abdomen.  The patient chose only to have the procedure done to his chest.

On 3/14/2013, the patient underwent pre-operative procedures and then Smart-Lipo surgery.  The surgery proceeded without any complications, but the medical records were difficult to read.  According to the patient, he was told it could take 6 months to see results.

On 3/22/2013, the patient returned to the internist’s clinic for his post-operative follow-up.  During this appointment, the patient expressed concerns that the swelling was more than he expected.  On 5/3/2013, the patient returned for another follow-up visit. During this visit, he indicated that he was not happy with his results as there was asymmetry between the left and right sides of his chest (the left side was larger than the right side).

On 9/23/2013, during the patient’s next follow-up appointment, it was suggested that revision surgery was needed on his left breast.  On 10/10/2013, the internist performed revision Smart-Lipo to the patient’s left breast. The patient never returned to the internist’s clinic.

The patient complained to the Board that he was not satisfied with the results.  After 6 months post-surgery, he continued to see problems with the left side of his chest.  He asked for a refund from the internist’s clinic, but it was denied.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records, lacked sufficient skill and knowledge to perform Smart-Lipo safely, and failed to recognize the signs and symptoms of gynecomastia as a possible source of the patient’s enlarged breast tissues.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for eat year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California


Date: April 2017


Specialty: Internal Medicine, Plastic Surgery


Symptom: Swelling


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Internal Medicine – Excessive Wound Drainage, Weakness, And Dizziness After Smart-Lipo On 32-Year-Old Obese Patient



On 9/18/2014, a 32-year-old female had a Smart-Lipo consultation with an internist.  On the patient registration form, the patient indicated that she was interested in Smart-Lipo to her upper and lower abdomen, hips, waist/flank area, back bra rolls, outer thighs, and upper arms.  She indicated that she had a history of anemia, cold sores, keloid scarring, irregular periods, and depression. On the “Smart-Lipo History Intake” form, the patient indicated that she was 5’0.5” tall and weighed 178 pounds.  Under a list of possible medical conditions that the patient had, the patient circled chest pain, recent weight loss or gain, cold sores, back pain, difficulty swallowing, depression, heart murmur, Lap-Band surgery in 2008, removal of Lap-Band in 2011, gastric sleeve in 2013, and removal of her gallbladder in 2014.  The patient indicated that she took Latuda for depression and has an ultrasound of her heart done every 5 years.

On 12/9/2014, the patient completed a second “Smart-Lipo History Intake” form.  On this form, the patient now indicated that she was suffering from anemia and “microvalve prolapse.”  She also listed her height as 5’1” with a weight of 190 pounds. On the “Pre-Operative Screening” form, the patient stated that she was taking Adderall, lansoprazole, and Latuda.  The patient’s weight was noted as 193.5 pounds with a BMI of 36.6. Measurements were also taken of the areas where surgery was to be performed. Blood was also collected for standard blood testing as well as an EKG.  The patient also completed a Smart Lipo “Pre-Operative Screening” form/High BMI consent form. The form explained what a high BMI is, what obesity is, and why an obese patient should have Smart-Lipo performed.

Also, the form stated that the patient must obtain medical clearance from her primary care provider before the internist performed the procedure.  The internist admitted during the interview with investigators on behalf of the Board that she never obtained medical clearance from any of the patient’s medical provides, despite the notation on the form.  The informed consent forms were completed by the patient and an LVN. The internist never went through the informed consent forms or discussed the risks and benefits of the surgery with the patient before the day or surgery.  The records also did not contain any documentation that the internist even discussed the risks and benefits of the surgery with the patient at any time.

On 12/16/2014, the internist performed Smart-Lipo on the patient’s hips, upper arm, upper and lower abdomen, and waist/flanks.  On the pre-printed Smart-Lipo OR Package form, it was noted that the patient “had a light meal before coming.” The NP checking in the patient did not document exactly what the “light meal” consisted of or when it was consumed.  The internist wrote that the patient had keloid scarring, but the location of the scarring was not legible. She also wrote that the patient was planning on having a tummy tuck in the future and had excessive skin laxity on her abdomen.  The internist listed the patient as ASA Category I. Prior to surgery, the pictures were taken of the patient showing “bat wing” deformity of the arms (hanging skin), truncal obesity, and smooth abdominal skin contour with small keloids.

According to the progress note, the procedure started at 1:00 p.m. and finished at 3:25 p.m.  About 30 minutes into the procedure, the patient complained of 8 out of 10 pain, and the comment portion of the note read ‘VV (2-3 sec).”  Then about an hour and twenty minutes into the procedure, the patient reported pain on a scale of 4 out of 10. During the two-hour and 15-minute surgery, the patient’s vital signs were not continuously monitored.

During the internist’s subject interview on 3/15/2016, the internist initially did not know what “VV (2-3 sec)” meant, but she eventually stated that she believed it meant the patient had a vasovagal episode, meaning she passed out during the procedure.  This is generally caused by sudden drops of blood pressure and heart rate.

According to the progress note, 10,720 ml of tumescent fluid was infused into the patient’s body, which contained 3,090 mg of lidocaine (the safe dose of lidocaine should never exceed 3,076.5 mg), and 4,240 ml of fluid was removed from the patient’s arms and abdomen, of which 1,900 ml was fat, which left 6,470 ml of tumescent fluid remaining in the patient.  The medical record failed to indicate where and how much fat was removed from each region the internist performed Smart-Lipo surgery on.

There was no indication in the medical record that the internist warmed the tumescent fluid to body temperature before infusing it into the patient.  There was also no indication in the medical record that the patient utilized compression boots during the surgery. The patient was discharged from the facility at 3:40 p.m. following a 30-minute observation period.

On 12/17/2014, the patient returned for her follow-up appointment.  She indicated that she was weak, her pain over the night was a 6 out of 10, approximately 2 cups of fluid drained from the surgical sites, and she was light headed.  It was difficult to determine from the medical record whether the internist ever saw the patient, but it did not appear that she did.

On 1/16/2015, the patient returned for her one-month follow-up appointment.  The measurements were taken, along with a height and weight. The patient still weighed 193 pounds with a BMI of 36.5.  In response to the question “How do you feel about your results”, the patient answered ‘good.”

On 6/8/2015, the patient returned for her 6-month follow-up appointment.  The patient reported that while she had seen improvements, she was not happy with the results of the Smart-Lipo surgery.  Measurements were taken along with the patient’s weight, showing a 7 pound weight gain. The internist wrote “skin laxity is an issue, will pursue tummy tuck.”  the internist did not recommend a revision surgery, and the patient never returned. According to the patient, the internist told her “she wasn’t a good candidate [for Smart-Lipo] to being with.”  She also complained that at the 6-month post-procedure mark, she gained 7 pounds, but her arms looked the same, and her stomach was deformed and protruded from her abdomen. Pictures were taken of the patient at several visits, but none of the photographs were dated making it impossible to determine the progress of the patient’s recovery.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records and warm the tumescent fluid to body temperature to avoid life-threatening arrhythmias and left an unsafe amount of fluid remaining in the patient.  The patient was not an appropriate candidate for the procedure, the internist lacked knowledge or understanding of the risks posed by infusing large amounts of tumescent fluid containing lidocaine while the patient was also taking Latuda and Adderall, a potentially fatal drug interaction.  Also, the internist failed to meet with the patient before the day of surgery to discuss the risks and benefits of the surgery with the patient and allowed an LVN to go through the informed consent process.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California


Date: April 2017


Specialty: Internal Medicine, Plastic Surgery


Symptom: Weakness/Fatigue, Dermatological Abnormality, Dizziness, Chest Pain, Wound Drainage


Diagnosis: Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with patient or patient relations, Failure to properly monitor patient, Improper medication management, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Internal Medicine – Uneven Smart-Lipo Procedure Results In Fat Mass



On 3/10/2010, a 48-year-old female had a consultation with an internist for VelaShape to her abdomen, waist, hips, and flanks.  The patient was recorded as 5’9” with a weight of 162 pounds and a BMI of 23.9. The patient received 10 VelaShape treatments from staff at the internist’s clinic between 6/24/2010 and 9/9/2010.

On 12/20/2013, the patient returned to the clinic for a Smart-Lipo consultation.  The “Pre-printed Medical history Intake” form did not contain any information connected to past or current medical conditions.  The patient then wrote “none” next to the questions regarding prior hospitalizations, prior surgeries, or medications. On the ‘Pre-Procedural Evaluation” form, the patient’s weight was listed as 167.8 with a BMI of 24.8.  The patient was interested in Smart-Lipo to her upper and lower abdomen, hips, and waist. The informed consent forms were completed by the patient and an LVN. The internist never went through the informed consent forms or discussed the risks and benefits of the surgery with the patient before the day of surgery.  The records also did not contain any documentation that the internist ever discussed the risks and benefits of the surgery with the patient at any time.

On 1/28/2014, the patient underwent Smart-Lipo to her upper abdomen, lower abdomen, and hips.  On the “Physician Charting” form, the internist wrote under the exam portion that the patient’s abdomen was normal and then wrote “Scoliosis, skin laxity.”  The patient received Keflex, Vicodin, and Ativan before the start of surgery, and then she received 50 mg of tramadol 55 minutes into the surgery. Despite this additional tramadol given, the “Physician Charting” form stated that the patient’s pain scale was a 0 out of 10 throughout the entire procedure.

According to the “Physician Charting” form, the internist infused the patient was 5.3 liters of tumescent fluid and removed 1,800 ml of aspirate, of which 800 ml was fat.  The chart did not indicate how much fat was removed from the specific areas. The patient’s vital signs were checked one time during the 1-hour and 24-minute procedure. The patient recovered for 16 minutes after the surgery, and her vital signs were checked one time before she was discharged home.

There was no indication in the medical record that the internist warmed the tumescent fluid to body temperature before infusing it into the patient.  There was also no indication in the medical record that the internist utilized compression boots during the surgery.

On 1/31/2014, the patient returned for her first post-operative follow-up appointment.  The handwritten note from an LVN listed the patient’s vital signs, that there was no sign of infection, that the patient was not in pain, and the patient was happy with the procedure.  The patient reported draining of fluid during the night, but otherwise slept well. There was no documentation that the internist saw the patient at this visit.

The patient returned her for 3-month and 6-month follow-up appointments on 5/7/2014 and 6/23/2014, respectively.  Photos and measurements were taken at each appointment as well as her weight and BMI. On 5/7/2014, the patient weighed 158 pounds, and on 6/23/2014, the patient weighed 161.5 pounds.  The internist wrote on the progress notes that the patient was doing well, and the patient was happy with the results. The internist did not indicate that any revision/correction surgery was needed.  On the progress note for the 6-month follow-up, the internist wrote “very weak abdominal wall muscle tone, advised core training exercises.” At the bottom of the June progress note, there was a handwritten note dated 8/4/2014 “Pt. wants to see if improvement seen.”  There was nothing further noted regarding this encounter.

On 9/3/2014, the patient returned for a “Mini Pre-Procedure Screening.”  The patient’s weight was now listed at 159.5 with a BMI of 23.6. Photos and measurements were also taken.  According to the note, the internist was to perform a revision surgery to the patient’s abdomen. Under the “Medications and Medical history Reviewed” section, “n/a” was written.

On 9/9/2014, the internist performed a revision surgery to the patient’s abdomen.  On the “operative Summary Report,” the internist wrote “very fibrous s/c [subcutaneous] tissue.”  The procedure started at 9:30 a.m. and was completed at 9:45 a.m. The internist infused the patient with 2 L of tumescent fluid, removed 400 ml of aspirate, and removed 200 ml of fat.  The patient’s vital signs were only taken at 9:00 a.m., before the surgery started. The internist discharged the patient 15 minutes later, at 10:00 a.m., from the clinic.

At the first and second post-operative follow-up appointments (at 3 days and one-month post-operative, respectively), the LVN did not note anything unusual in the record.  According to the LVN, the patient was happy with the procedure at this stage in her recovery. The LVN also noted in the one-month follow-up appointment note that the patient was “educated on proper diet and exercise.”  Only circumference measurements of the patient’s abdomen were taken. There was no documentation that the internist saw the patient during these two appointments.

On 2/26/2015, the patient returned for her 6-month follow-up appointment.  The patient’s weight was noted as 160 pounds with a BMI of 23.6. The internist wrote “small ventral hernia or rectus diastasis” and “improved appearance.”  The photos of the patient showed a smooth abdominal contour to the patient before the Smart-Lipo surgery while there was waviness to the skin afterwards. The internist did not recommend any further revision or correction nor did she explain her comment about a possible hernia or rectus diastasis.  There was no physical examination noted. The patient never returned to the internist’s clinic.

Following the internist’s comments about the patient having either a hernia or rectus diastasis, the patient was seen by another physician for the mass in her upper abdomen.  The mass developed following the second Smart-Lipo procedure performed by the internist. An ultrasound on 7/17/2015 did not reveal any abnormality, including a ventral hernia.  There was also no evidence of a mass or fluid in the patient’s abdomen, indicating the mass was residual fat from the unevenly performed Smart-Lipo by the internist.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records, failed to conduct an appropriate history and physical examination, performed Smart-Lipo on a patient being treated and medicated for major depressive disorder, failed to meet with the patient before the date of surgery to discuss the risks and benefits of the surgery with the patient, and demonstrated a lack of knowledge or understanding by performing Smart-Lipo on patients for weight-loss purposes.  The patient was also not an appropriate candidate for the procedure.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for eat year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California


Date: April 2017


Specialty: Internal Medicine, Plastic Surgery


Symptom: Mass (Breast Mass, Lump, etc.)


Diagnosis: N/A


Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with patient or patient relations, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Internal Medicine – Body Sculpting By Smart-Lipo Of Thighs, Hips, And Waist And Unsatisfactory Results



In May 2011, a 61-year-old female was seen by an internist to provide body contouring to her outer thighs, hips, flanks, and waist/abdomen area.  The patient had previously undergone a complete abdominoplasty in January 2011 by another physician, but she wanted additional body sculpting.

On 6/3/2011, the internist performed Smart-Lipo on the patient on her inner/outer thighs, hips, and waist.  On the day of the surgery, the patient told the internist that, years before, she had undergone liposuction and breast augmentation.  Prior to surgery, the internist reviewed blood work and an EKG study. The only abnormal finding was a slightly elevated blood glucose level.

On 7/8/2011, the internist performed Smart-Lipo on the patient’s upper and lower abdominal region.  The internist also contoured the patient’s pubic area, which was not discussed beforehand, nor was the patient charged for this.

At several post-operative visits, including on 7/11/2011, the patient expressed dissatisfaction with the results.  At a follow-up appointment on 12/2/2011, the internist prescribed phentermine for weight loss, but the patient suffered side effects and was taken off of the medication the following week.

On 5/4/2012, the internist performed revision surgery on the patient’s hips and outer thighs.  The internist did not order new EKG studies or labwork before the surgery, almost one year after the previous studies were done.  The internist also did not review or contact the patient’s primary care provider to ensure there were not any changes to the patient’s health in the previous year.  At follow-up appointments, the patient continued to complain of the results, including asymmetry with the inner and outer thighs and her pubic region. The patient requested that the internist do another Smart-Lipo procedure.  The internist initially refused to do the procedure, but eventually agreed even though she wrote in the patient’s medical record that the patient would not benefit from a further revision surgery.

The internist admitted during her interview with an investigator of the health Quality Investigations Unit for the Medical Board on 4/24/2014 that she agreed to do the additional surgery despite not providing any benefit to the patient because the patient claimed to be a physician, and this was “elective cosmetic surgery.”

On 12/5/2012, the internist performed Smart-Lipo on the patient’s upper abdomen, inner thighs, and right hip.  The internist did not order new EKG studies or lab work before the surgery. The internist encountered fibrosis during the procedure.  The patient continued to complain about the results and requested more procedures. The internist finally refused the patient’s request for more surgery and offered to do free laser hair removal instead.  The patient never returned to the internist’s clinic.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to order repeat blood work and EKG studies and contact the patient’s primary care provider to determine if there were any changes in the patient’s health before the 5/4/2012 Smart-Lipo procedure and 12/5/2012 Smart-Lipo procedure.  The internist also performed a surgical procedure on the patient because the patient wanted additional surgery despite acknowledging it was not in the patient’s best interest, and she lacked sufficient skills and knowledge to perform Smart-Lipo safely, including knowledge about alternative body contouring procedures that might be more beneficial to her patients.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), medical record keeping course, education course (at least 25 hours per year for eat year of probation), and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California


Date: April 2017


Specialty: Internal Medicine, Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Physician concern overridden, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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