May 2, 2001

The beauty butchers

The 'completely preventable' death of a Vietnamese woman -- believed to be the first person in Canada to die at the hands of an unlicensed surgeon -- illustrates the frightening proliferation of underground clinics

Christie Blatchford National Post

TORONTO - At 11:09 on the morning of March 19, a perfectly healthy woman named Thi Hanh Lan Tran was chatting on her cellphone.

By 1:30 p.m. the same day, she was deposited, vital signs absent, at Toronto Western Hospital by two people who told emergency room staff that the petite 36-year-old had had a seizure in a bus shelter and was frothing at the mouth.

Doctors got Mrs. Tran's heart started, but they were baffled as to what might have happened. The only clues were the fresh needle punctures on her forearms.

At first blush, it looked as though they had a case of a drug addict overdosing.

The woman's 43-year-old husband, Kiet Nguyen, who speaks only a little English and who had earlier that morning dropped off his wife at the beauty salon where she worked as a freelance manicurist, was so devastated he could barely talk.

But the one thing he was adamant about was that his wife didn't use drugs. So, too, was the couple's teenage daughter.

Yet Mrs. Tran had been in a car accident recently and had been in considerable pain. It all appeared to fit: Perhaps she had begun self-medicating.

Then, the doctors noticed a series of tiny pinpricks beneath both her breasts.

There had been no seizure in a bus shelter and Mrs. Tran's family was right: She was no drug user, but rather the victim of a cut-rate, backroom breast augmentation that went terribly wrong. The multiple pinpricks under her breasts were injection sites for the local anaesthetic -- with toxicology tests incomplete, the drugs are as yet undetermined -- preparatory to the surgery itself.

Mrs. Tran was formally pronounced dead at 12:20 p.m. the next day, the official cause of death was cardiac arrest, likely as a reaction to the freezing agent, a sedative it appears she was given first and which explains the punctures on her arms, or both.

She is believed to be the first person in Canada to die from unlicensed cosmetic surgery.

Toronto Police have issued a warrant for criminal negligence causing death for Minh Tam Thi Le, a Vietnamese national who arrived here last fall on a multiple-entry student visa, which means she is not required to check in with immigration and authorities have no way of tracking her movements.

She was working under the names of Dr. Crystal Lee and Dr. Minh Tam, and had been performing bogus surgeries since November out of four makeshift ground-floor rooms in a former rehabilitation hospital on Dewson Street in west-end Toronto. It remains unclear whether Mrs. Le has had any medical training in Vietnam, but certainly, she is unlicensed by the Ontario College of Physicians and Surgeons.

Her partner in the makeshift clinic, Tu Ngoc Nguyen, was arrested last week and also charged with the same offence.

Mrs. Tran's death -- which Dr. Barry McLellan, the regional supervising coroner, believes was "completely preventable" -- has stunned police, officials at the coroner's office and the mainstream community.

And the fact that she died has shaken even the legitimate plastic surgeons who for years have been quietly treating what one of them calls "the walking wounded" of such underground procedures.

"This lady was at the extreme end of the pendulum, but even so, even in the worst-case scenario, I would not have thought it possible that someone could die [of a botched job] in this country," Dr. Robert Stubbs, one of the city's best-known plastic surgeons, said this week.

But that such illicit surgeries have been going on, or that, as Dr. Stubbs said, "there are pseudo-surgeons masquerading in backroom clinics" is hardly news to those, like the Yorkville Avenue doctor, who regularly do repairs on the survivors of illegal procedures.

Dr. Stubbs has seen two Vietnamese-Canadian men who had botched penis-lengthening surgery at fly-by-night facilities in the United States, one of whom, he said, "was unable to have sex for five years." Dr. Stubbs' late partner once saw an Asian woman whose face likely had been injected with silicone window caulking; Dr. Stubbs still has a picture of the woman, her nose ravaged by the raging infection that set in.

Dr. Collin Hong, a Willowdale, Ont., plastic surgeon, also "quite often" sees the victims of such butchery -- usually Asian women who have had window caulking or something equally unsterile and inert injected into their lips, eyes or breasts.

Ironically, such injections may initially yield wonderful results, he said.

But sometimes, the body rejects the foreign material, infection impregnates the tissue, and the result is fistulization -- basically, chronic, leaking sores. Even absent infection, non-sterile freely injected silicone may, within months or years, bind with the body tissues and harden or become lumpy, rather like having Plasticine woven throughout the area.

"It's often irreversible," Dr. Hong told the National Post. "You cannot remove it in the breast without mastectomy." His best advice to such patients, he said, is often, "Do nothing" because to do anything would require such drastic surgery.

Dr. Hong once treated a 49-year-old Ottawa woman, who had her procedures done in Vietnam: Her nose was completely destroyed, the nostrils distorted and raised as a result of the festering infection that followed injections of unknown material. "She was suicidal when I saw her," he said. "How could anyone be so heartless? She really didn't look like a human." Even after his several skilled repairs, the woman's nose remains clearly deformed, though much improved. "At least she can go out now."

He said there are different levels of repairs that come his way -- the least of which are the smaller procedures such as mole removal or laser treatments done by untrained estheticians in beauty parlours, the worst, the "blatant, total violations done by people with no medical licence -- and that's a big problem."

For all the complicated reasons that send people to the backrooms, price is always a part of it, Dr. Hong said.

For instance, according to Detective-Sergeant Ralph Brookes, Toronto Police know Mrs. Tran was eventually slated to have three procedures, though it appears only preparations for the breast augmentation were started the day she suffered her fatal heart attack. But she was scheduled to also have her eyes made rounder --this is called "blepharoplasty" and means adding an eyelid fold where there may be none -- and thus more Western looking, and her lips injected for a bee-stung effect.

The total bill for the three procedures was to have been $2,500, this for "$10,000 worth of surgery," according to Dr. Stubbs.

Just the saline-filled breast implants that are used in this country cost doctors $1,200 a pair.

What Mrs. Tran wasn't paying for was, of course, the skill of her "surgeon," but also the expensive life-saving equipment and monitors that legitimate doctors have at hand in their surgeries.

As coroner Dr. McLellan said, at a reputable clinic, her sedation would have been monitored; continuous electrocardiograph would have noticed any significant change in her heart rate; she would have had an oxygen saturation monitor on her finger to pick up a telltale drop; trained eyes would have been watching her colour.

"If someone is having a drug reaction," Dr. McLellan said, "there may be changes in their heart rate; it may be very fast, or very slow. The oxygen will drop; they may become less responsive. Their colour will change. Trained personnel would have recognized these changes early, they would have intervened -- an antidote to the drug, supported her breathing, managed a seizure. So far as we can tell, her death was completely preventable."

As Dr. Stubbs said with evident frustration, "We have backup. We could have defibrillated her ... we would have had an intravenous line in, we have ventilators."

Properly performed cosmetic surgery by reputable plastic surgeons is remarkably safe. Yet even so, practically the first caution on the consent form Dr. Stubbs has his patients read and sign is that death is a possible outcome. This is informed consent; it is doubtful Mrs. Tran had remotely enough information to have given that.

The mysterious Mrs. Le -- police still have no idea where she is -- reportedly had a busy practice going. The clinic wasn't among those whose carefully worded advertisements -- "surgery" is a word rarely used -- regularly appear in the handful of Vietnamese newspapers and magazines in the Toronto area.

It was the plethora of these ads, "probably none of which has a doctor behind them," which recently led Dr. Hong to advertise in the Vietnamese weekly Thoi Bao -- just so the most vulnerable target population, the poor or poorly educated or non-English speakers who wouldn't be exposed to mainstream media, would have a basis of comparison.

Patients were referred to Mrs. Le; her's was a word-of-mouth operation.

And that, said Dr. Stubbs, "tells me that those who are doing this kind of surgery are being protected by those who are having it done." The payoff, of course, is that the procedure might be successful. As Dr. Stubbs said, people wouldn't continue to go if all the work at the illicit clinics was as disastrous as Mrs. Tran's. There are, presumably, satisfied customers out there -- or at least those not so dissatisfied they are willing to complain. Drs. Stubbs and Hong see only those whose lives are ruined by the results.

The illicit clinics -- and Dr. Hong has seen ads for as many as 10 in the Vietnamese press -- exist in a regulatory gap: The College of Physicians and Surgeons governs only accredited physicians. As Det.-Sgt. Brookes said last week, "It's fraud, what these places are doing." It may well be properly a police matter. But how are the police to police a crime that, until Mrs. Tran died, until there was a death, appeared to be victimless, complainant-less?

As for what drives people to backroom clinics that are, like Mrs. Le's was, clearly low-rent and disreputable -- Mrs. Tran would have entered the ramshackle Dewson Street building by a back door amid a rabbit warren of fire escapes, sat in a barren waiting room with three chairs, and then entered an "operating room" that was a former administration office -- the answer is complex.

Patient motivation may be simple, what Dr. Stubbs described as the desire of the new immigrant to assimilate quickly, and who, ironically, may well end up in the hands of "immigrant populations whose doctors are questionably trained, but tired of waiting on tables and driving taxis." It may be benign, a manifestation of the universal human desire to appear younger or prettier, or tied up with sexual confidence. For Asian women, even those entirely at ease in their own milieu, part of it is cultural.

Last year, Ann Shin, a Korean-Canadian filmmaker, made a documentary for the National Film Board called Western Eyes. The film follows two young women as they wrestle with whether they should have their eyes done.

Ms. Shin interviewed about two dozen women.

"Everyone I spoke to," she told the Post, "felt fairly happy with their ethnic heritage; they spoke the language of their parents. They just wanted to look better. So on one level, it's the same as anyone else wanting cosmetic surgery. But if you step back and think, 'Why the eyes?', at least that one procedure has to do with trying to go for a white ideal."

Mrs. Tran and her husband came to Canada in 1994. He's a goldsmith by trade; she had a table at a beauty salon in a west-end mall where sometimes she brought the boss spring rolls. The family lives in a small apartment in a rundown building off Toronto's downtown Chinatown. Mrs. Tran wasn't rich; she must have been saving for her procedure for years. Her husband had no idea, the police said last week, that she had booked the surgery: He was left utterly reeling. Det.-Sgt. Brookes remembered seeing him at the station afterward with Detective-Constable Joe Nguyen: "Disaster was written in his posture."

Det.-Sgt. Brookes is particularly furious about one element of what happened to Mrs. Tran, before she was dropped off at the hospital. After the procedure went awry, Mrs. Tran in crisis, "They took the time to clean her off. That's the thing. Who knows how long that took?"


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