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Silas Walker, Deseret News
The grave site of Lynne Brimley, a mother of five and grandmother of 20, who went to Portica Body & Face for liposuction in 2016 and 24 hours later was dead, at Mountain View Memorial Estates Cemetery Salt Lake City on Friday, April 5, 2019.
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Editor's note: This is the first in a series investigating the cosmetic surgery industry in Utah and around the nation

SALT LAKE CITY — She thought it was safe. It’s the second most common cosmetic procedure, a quick fix for those last stubborn pounds.

But in February 2016, a Utah mother and grandmother went home after having liposuction and died during the night.

Three years later, hardly anyone knows how or why.

Not the clients, or potential clients, of Dr. Jennifer W. Allen, the physician who performed the procedure and who still offers liposuction at her office at a Salt Lake City mall.

Not other doctors in Utah who could benefit from learning how the second most common surgical aesthetic procedure can turn deadly.

Not anyone searching through the state database that reports on disciplinary actions against physicians.

Not even friends and relatives of Lynne Brimley, whose obituary said only that the “noble and devoted daughter of her Heavenly Father was taken home unexpectedly.”

Silas Walker, Deseret News
The grave site of Lynne Brimley, a mother of five and grandmother of 20, who went to Portica Body & Face for liposuction in 2016 and 24 hours later was dead, at Mountain View Memorial Estates Cemetery in Salt Lake City on Friday, April 5, 2019.

To learn the circumstances surrounding Brimley’s death, they’d have to search through the records of Utah's 3rd District Court, where Brimley’s husband and adult children filed a wrongful-death suit against Allen and Portica Body & Face in August 2017.

Patients can die after surgery even if a doctor does everything right. Allen, who did not respond to multiple requests for comment by the Deseret News, denied in court filings that she did anything wrong.

But Brimley’s death illuminates an ugly truth in the beauty business: The rapid growth of aesthetic medicine — driven by consumer demand and an ever-widening pool of doctors who offer the procedures — has created an industry that largely operates in secret.

It operates in secret, in part, because many men and women who seek cosmetic services prefer not to advertise that they’ve had the work done.

And it operates in secret because people who have liposuction, tummy tucks and breast lifts or augmentation pay for them with cash or credit cards, leaving no billing records from Medicare or private insurance with which to calculate the overall numbers of procedures and the incidence of calamity, as is done when knees are replaced or gall bladders removed.

Joseph Tolman

Here's what we do know: In 2018, Americans had 17.7 million surgical and non-invasive cosmetic procedures (such as Botox or dermal fillers) in the offices of board-certified plastic surgeons who voluntarily reported their numbers to the American Society of Plastic Surgeons.

Salt Lake City ranked fifth in the nation for the number of plastic surgeons per capita in 2018, behind Miami, Los Angeles, New Orleans and Austin, Texas, according to RealSelf, an online review and information site for cosmetic procedures.

These procedures, when performed by highly trained physicians, are largely safe. But 1 in 61 cosmetic surgeries performed by plastic surgeons have complications, according to CosmetAssure, a Birmingham, Alabama, company that provides insurance for patients of board-certified plastic surgeons.

And the rate can climb to as high as 1 in 32 for one of the riskiest procedures, the abdominoplasty or "tummy tuck," according to CosmetAssure, which collects only information on complications, not deaths.

But those are complication rates for plastic surgeons who have a minimum of five years of general surgery training and three years of plastic surgery training before sitting for written and oral exams.

They don’t reflect procedures gone wrong at the office of a family physician or gynecologist, or at the more than 2,000 "medical spas" across the nation.

The gap in reporting exists because there's no one charged with keeping count and because any licensed physician can legally perform any type of surgery, from brain surgery to a C-section, whether or not they’ve had specialized training.

“As a technical matter, I don’t think people are doing major spine surgeries and they’re certainly not doing heart surgeries in the back office, but they do all kinds of face-lifts, all kinds of breast reductions and breast augmentations, and all kinds of plastic surgery ... in the back office,” said G. Eric Nielson, a Holladay-based medical malpractice attorney who has been practicing for 33 years, and who represented the Brimley family.

When things go wrong in Utah, the Division of Occupational and Professional Licensing has the power to revoke or suspend a physician’s license, and publishes disciplinary actions in a monthly newsletter. (So far this year, four physicians have surrendered their license to practice, and another had his license revoked.)

If a complaint is filed against a physician, DOPL will then open an investigation into that physician. If a medical malpractice suit is filed against a physician, the case is heard by a professional licensing pre-litigation panel before it can go to court.

“Under Utah law, meritorious rulings from a pre-litigation panel are automatically referred to DOPL investigations. In addition, an adverse action taken by a facility against a health care practitioner by law is required to be reported to DOPL. However, not every court case involving a licensee automatically becomes a disciplinary action,” Jennifer Bolton, public information officer for the Utah Department of Commerce, said in an email.

The licensing organization said it “can neither confirm nor deny” that an investigation into Brimley's death is taking place.

Unless the agency takes action, in the form of a suspension, probation, license revocation, or other disciplinary action, the public has no way of knowing if a physician is under investigation, or for what.

In other words, the doctor you’re thinking about using for liposuction or a face-lift may have had a patient die after a procedure or have a history of complications, and under the current system, you may never know.

What counts as 'board-certified'?

The most dangerous procedure in cosmetic medicine right now is gluteal fat grafting, more commonly known as the Brazilian butt lift, according to Dr. Arthur W. Perry, a board-certified plastic surgeon in New York and New Jersey. That procedure could have a death rate approaching 1 in 3,000, according to the American Society of Plastic Surgeons, which issued a warning about the procedure last year.

For liposuction, one study published in 2000 in the journal Plastic Reconstructive Surgery put the death rate at 1 in every 5,000 procedures, although liposuction has become much safer since then, Perry says.

But the true number of complications and deaths is unknown because of uneven reporting standards across states and specialties, industry experts say.

One study on complications said their incidence in liposuction ranges from zero to 10 percent, “with inconsistencies of reported data between different specialties, such as plastic surgery and dermatology, making an accurate assessment of the risk profile of cosmetic liposuction challenging.”

That study, conducted by physicians at Vanderbilt University and the University of Alabama, was published in 2017 in the Aesthetic Surgery Journal. It surveyed the outcomes of 31,010 procedures and identified 759 cases with major complications, for an overall rate of 2.4 percent. But the cases all involved an emergency room visit or hospital admission.

Under this criteria, Lynne Brimley’s death wouldn’t have been recorded since she died at home.

" I shouldn’t have a death in liposuction in my backyard that I didn’t know about. "
Dr. York Yates, a board-certified plastic surgeon in Layton, Utah

Patients die in hospitals, of course, and for a wide range of reasons, including physician error and poor health going into surgery. A physician can be well-trained and do everything right and still lose a patient. "There's a difference between a bad result and negligence," Perry said.

Dr. York Yates, a board-certified plastic surgeon in Layton, Utah, said he doesn't believe that every patient death should make the front page or be revealed to other patients of a practice. But he was troubled that he hadn’t heard about Brimley’s death, not even casually.

“I shouldn’t have a death in liposuction in my backyard that I didn’t know about,” he said.

Alex Thiersch, founder and director of the Chicago-based American Med Spa Association, said there has long been tension between plastic surgeons and physicians trained in other specialties, such as family medicine or obstetrics, but who call themselves cosmetic surgeons, as Allen does.

The plastic surgeons say the certification that should most matter to consumers is the credential issued by the American Board of Plastic Surgery, and they bristle at family doctors calling themselves surgeons.

On her website, Allen says that she is board-certified as a family physician, and that she changed the focus of practice to aesthetics in 2008.

www.portica.net
Dr. Jennifer Allen pictured on Portica Body & Face's website, 2019.

"From 2008-2011 she worked with multiple cosmetic and plastic surgeons around the country which provided invaluable hands-on training experiences. During this time she also attended multiple live courses and workshops to solidify and refine her skills," the Portica website says of Allen's training.

When consumers are confronted with impressive-sounding, framed credentials, it can be difficult to distinguish between who is qualified to perform these procedures and who is not.

Heather Tuttle

The phrase “board-certified plastic surgeon” usually means that a physician has been certified by the American Board of Plastic Surgery, which is a member of the American Board of Medical Specialties, the respected nonprofit that sets the professional and educational standards doctors must meet in order to obtain certification in 24 specialities. However, none of the ABMS’ member boards certify cosmetic or aesthetic surgeons.

As a result, several independent boards have been formed to certify cosmetic and aesthetic surgeons, including the American Board of Cosmetic Surgery and the American Board of Facial Cosmetic Surgery. (In California, members of the American Board of Cosmetic Surgery are not allowed to call themselves “board-certified” — only those certified through the American Board of Plastic Surgery can.)

In order to be certified by the American Board of Cosmetic Surgery, doctors must graduate with an M.D. or D.O. from an accredited medical school, be board-certified by one of four certifying boards in one of 10 medical specialties related to cosmetic surgery, spend a full year training exclusively in cosmetic surgery, perform at least 300 cosmetic surgery procedures in fellowship, train in non-surgical cosmetic procedures, and pass a two-day oral and written exam. They must also operate in accredited surgery centers.

The American Board of Plastic Surgery requires that, before sitting for oral and written exams, physicians complete five years of a general surgery residency and an additional three to six years of plastic surgery training.

Conversely, some framed certificates may signify only that the doctor has attended a training class and paid a fee to join an association. And a certificate of attendance doesn't necessarily signify competence. For the prospective client, that means "it's a little bit of buyer beware," Thiersch said.

‘Fresh, pretty, natural’

Lynne Brimley, who lived in Holladay, Utah, loved the ocean, and loved books. “Lynne felt about as close to heaven as she could get here on this earth while she was next to the surf enjoying her favorite pastime of reading,” her obituary said, giving her age as “72 years young.”

Legacy.com
An obituary photo of Lynne Brimley published in the Deseret News in 2016.

Born in Salt Lake City in 1943, Lynne Jenkins met her future husband, Richard, when they were in high school. After she earned a degree in English from the University of Utah and attended graduate school, the couple were married in the Salt Lake Temple of The Church of Jesus Christ of Latter-day Saints when she was 22. Two years later, they started their family in a house a few blocks from where both of them had grown up.

Lynne Brimley was “completely devoted in every possible way” to her five children, her obituary said. She never missed a sports event, school function or church meeting when her children were involved.

But she didn’t sacrifice her own life to motherhood; she and her husband bought a houseboat that they kept at Lake Powell, and they worked together in real estate. They were also active in their church, serving a full-time mission in Salt Lake City at the time of Brimley's death, and her frequent volunteer work included working at a free medical clinic.

Brimley's daughter, Bridget Thackeray of Cottonwood Heights, said her mother was always energetic; even in her eighth decade, Brimley did Pilates every day. Over the years, she also ran a couple of businesses, including a wedding-dress boutique in Salt Lake City and a gift shop in Sun Valley, Idaho.

She loved to vacation in Southern California and Mexico; in fact, the photo for her obituary was one taken during a family vacation at a beach in Mexico.

But when Brimley decided to have liposuction, she didn’t opt for risky medical tourism in one of the countries where Americans have suffered complications, prompting the Centers for Disease Control and Prevention to issue a warning against having surgery in the Dominican Republic.

She opted for a small, one-doctor office close to home.

According to court documents, Brimley went to Portica Body & Face on Foothill Drive in Salt Lake City on Feb. 18, 2016, for “tumescent liposuction of (the) abdomen, flank and mid back with autologous fat transfer to the face and buttocks.”

Euphemistically called “volume replacement” on the Portica website, the procedure promises two-fold results — reduction of fat where the client doesn’t want it, and a subtle rounding of flesh elsewhere that restores a “fresh, pretty, natural look more than a face-lift would.”

It was a Thursday, and Brimley left home before sunrise for the procedure, which began at 7:50 a.m. and didn’t end until 4:40 p.m. She left the office around 5 p.m., carrying a prescription for the painkiller Percocet, and her husband drove her home.

In conversations with the Deseret News, plastic surgeons said the length of the surgery, regardless of what transpired during it, was unusual and potentially troubling, particularly for a patient in her 70s.

"There’s no question the complication rate is linearly related to the length of time on the operating room table," Perry said. "In general, most of us try to keep procedures 4-6 hours, and that’s about tops."

The court documents do not describe what happened between the time Brimley left Allen's office and her death. But Thackeray, Brimley's daughter, said that her father made sure that her mother got up and walked around every few hours, as Allen had told her to do.

"He got her up to walk her around during the night, maybe around 2 or 3 in the morning. They did a lap around the house, and he took her back to bed, and when he woke up, she was gone," Thackeray said.

Upon discovering that his wife was not breathing, Richard Brimley called 911 and performed CPR, but paramedics pronounced his wife dead when they arrived.

Seventeen months later, Brimley’s husband and adult children filed a lawsuit in Salt Lake County, alleging, among other things, that Allen exaggerated her credentials, "strongly implying that she was a qualified surgeon, when she was actually a family practitioner."

The lawsuit also charged that Allen infused “excessive amounts of fluid and drugs” into Brimley, was assisted by someone not licensed to be a medical assistant, and improperly discharged Brimley without medical monitoring.

" We need to operate on healthy patients. Cosmetic surgery is, let's face it, for vanity, and yes, it improves self-esteem. "
Dr. Arthur W. Perry, a board-certified plastic surgeon in New Jersey

In the response, filed a month later, Allen denied all allegations of wrongdoing, and said the discovery process may reveal that family members were “contributorily negligent" in the assumption of risk.

Perry was not familiar with the Brimley case and would not speculate on the allegations made by the family. But he said that the health of a patient is paramount, and that he requires his patients to be cleared for surgery by a board-certified internist.

"We need to operate on healthy patients. Cosmetic surgery is, let's face it, for vanity, and yes, it improves self-esteem. ... But nobody ever died of small buttocks," Perry said.

People with life-threatening problems have to accept the risk of surgery, he said, "but we have to think very carefully about whether you should assume those risks and potentially put your life at risk for the sake of vanity."

Allen did not respond to repeated phone calls and emails from the Deseret News regarding this case, and a reporter who went to her office twice was unable to see her. Allen's attorneys declined to comment on the case.

Little regulation

Across the U.S., about 1 in 10 family physicians have added cosmetic services to their practice. Some say the cash that comes in from these services helps support the rest of the practice. According to the American Med Spa Association, the average revenue of medical spas in 2016 was $945,000. (The association has 39 members in Utah.)

Plastic surgeons have aggressively fought the trend, arguing that cosmetic procedures are best done by those who had extensive training in reshaping and beautifying the face and body through plastic surgery residencies.

But doctors who call themselves cosmetic surgeons counter that they spend more time doing cosmetic procedures than plastic surgeons do, making them more experienced than doctors who spend much of their time on medically indicated surgery, such as facial reconstruction after an accident.

Regardless of who is right, “That ship has left the port,” says Thiersch, founder and director of the American Med Spa Association, colloquially known as AmSpa.

Consumers have shown they are comfortable with going to medical spas, instead of plastic surgeons’ offices, because they cost less and can be less intimidating than a traditional medical setting, Thiersch said.

Take Portica Body & Face, which has a small but pleasant lobby lit by the sun streaming through a large window behind the receptionist’s desk. On a recent visit, the room was scented with eucalyptus, evoking the calm and relaxation one feels after getting a massage or stepping out of a sauna, and potted plants and flowers were placed around the lobby.

Silas Walker, Deseret News
The front of Portica Body & Face in Salt Lake City, Utah, on Friday, April 5, 2019. In 2016, a mother of five and grandmother of 20 went to Portica to see a physician for liposuction and 24 hours later was dead.

Some doctors who expand into aesthetics stick to minimally invasive procedures, which comprise the bulk of aesthetic services in the U.S. According to the American Society of Plastic Surgeons, there were about 15.9 million minimally invasive procedures, such as Botox and dermal fillers, in 2018, while there were 1.8 million cosmetic surgeries such as liposuction and tummy tucks.

Those numbers represent only procedures done by board-certified plastic surgeons; there's no accounting of those done by physicians in other specialties.

In the U.S., a medical license is “unrestricted,” meaning a doctor can operate on any part of the body — heart, gallbladder or face. They don’t need to prove to anyone that they’re good at it; all they need is the patient’s consent and a sterile room.

Hospitals, for the most part, act as gatekeepers, only authorizing surgeons whose credentials meet their stringent standards. But doctors can establish their own one-room surgical suites in their offices with less regulation.

Any surgical center that has two or more surgery suites is required to be licensed and inspected by the Utah Department of Health, but physicians with a one-room surgical suite in their office are allowed to operate without a license from the Department of Health, said Joel Hoffman, the department’s director of the Bureau of Health Facility Licensing and Certification.

This means these one-room suites aren’t inspected by the Department of Health to ensure they’re meeting health, sanitation, patient treatment, equipment, personnel or safety standards, Hoffman said.

“There’s no one that regulates it,” he said. “There’s no check-in that I know of, not at all.”

Hoffman confirmed that Portica Body & Face is not licensed or inspected by the Department of Health.

Silas Walker, Deseret News
The front of Portica Body & Face in Salt Lake City on Friday, April 5, 2019. In 2016, a mother of five and grandmother of 20 went to Portica to see a physician for liposuction and 24 hours later was dead.

Portica is located in an office building in the Foothill Village Shopping Center, near Stein Mart, a CorePower Yoga studio, nail and hair salons and a AAA insurance office. Across the parking lot is a Red Butte Cafe.

Although it may seem counterintuitive that one could undergo liposuction near a Stein Mart, the presence of the discount department store is oddly comforting. It seems to indicate that the surgical procedures going on nearby are nothing serious — that after a quick “lunchtime lipo” session, you could go shopping or grab something to eat.

In reality, like any type of surgery, the procedure carries risks that multiply if the client is overweight, has other health issues, or is having other work done at the same time.

'Lunchtime lipo'

Bridget Thackeray didn't know her mom was having lipo.

Lynne Brimley hadn’t mentioned it, even though they were together the day before the surgery, and they were close, “as close as you can get.” Thackeray was Brimley's only living daughter, having lost another daughter, at age 10, to cancer.

“She was my best friend, my person,” Thackeray said recently, pausing to fight back a sob.

“At first, you don’t want to tell people how she passed away," Thackeray said. "Now, it seems that everyone has these kinds of things done. But she was very quiet about it; she’d only told my dad."

Both in the world and in the U.S., liposuction is the second most common cosmetic surgery, behind breast augmentation. In 2018, more than 258,000 people had the procedure performed by board-certified plastic surgeons, up 5 percent from previous years, according to the American Society of Plastic Surgeons. The average cost was $3,518.

In the CosmetAssure study of more than 30,000 liposuction procedures, about 2.4 percent resulted in complications. (CosmetAssure does not track deaths.)

When things go wrong, they can go catastrophically wrong. In addition to infection and hematomas, the most common complications involve the heart and potentially deadly blood clots.

As such, for many doctors, liposuction straddles a line in cosmetic medicine that they won’t cross.

Dr. Stephanie Singer, an OB-GYN in Park City who offers an aesthetics menu that includes fillers, lasers and thread lifts, doesn’t do liposuction, noting that its complications can include embolisms and nerve damage.

“So many plastic surgeons have been doing it for so long; let them do that, because that’s just what they’re really good at,” Singer said.

" There's no policy right now, in my state and I think in most states, that requires licensure for you to operate in your own office. "
Dr. York Yates, a board-certified plastic surgeon in Layton, Utah

Yet liposuction is often marketed as simple and safe, so much so that one New York doctor advertises “lunchtime lipo” and another promotes “bridal liposuction” as part of pre-wedding preparations.

Yates, the plastic surgeon in Layton, said he understands why some people are bothered by the ability of doctors to perform any sort of surgery, regardless of their specialty. Under the current system, the burden is on the consumer to distinguish from well-trained cosmetic surgeons and those he calls "rogues" — the ones who take weekend courses and then are essentially self-taught.

"There's no policy right now, in my state and I think in most states, that requires licensure for you to operate in your own office," he said. To make a change would require new regulations, certification and paperwork in a field that is already groaning from bureaucracy.

“It would be an enormous burden and expense, a lot of red tape and bureaucracy in my own practice, as someone who’s doing things right, to have legalities step in and maybe run the show a little bit more. But I think it’s probably time," Yates said.

"Every part of me wants that not to happen. ... But at the same time, for patient safety, I don’t know what else to do because we as surgeons are extremely poor at policing ourselves, it turns out,” he said.

Unanswered texts

On the morning that her father was performing CPR on her mother, Thackeray was headed to her daughter's school for a Presidents Day event. She thought it was something her mother might enjoy, too, so she texted her mother to meet her there.

They had grown especially close of late, since Thackeray and her family had been living with her parents during a home renovation. She'd only moved back into her own home a week ago.

Thackeray thought it odd that her mother didn't reply to multiple texts, and didn't find out why until her father called as she was leaving the event.

Three years later, she finds it difficult to talk about the loss of her mother without crying. Theirs was a family that did everything together, including vacations; Thackeray and Brimley talked every day.

In the past few years, she's been with other women when the subject of cosmetic surgery comes up; what friends have had done, or what they've like to have done.

"My blood runs cold when I hear things like that," she said. "Because no one knows."

Brimley was buried at Mountain View Memorial Cemetery, next to her daughter, Kerry, and close to Brimley's parents.

A few months after the funeral, her family hired Nielson, who said he was unable to talk to the Deseret News about the specifics of the case.

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Their lawsuit charged that Allen displayed a “knowing and reckless indifference” to the safety of her patient, and asked for punitive damages that would compensate the family for their pain and suffering, for funeral expenses, lost wages and earning capacity and loss of household services.

Both the Brimley family and Allen requested a jury trial, but it never took place.

The case was settled out of court, with the stipulation that neither party speak publicly about the settlement.

As of press time, Allen’s license remains in good standing.