Plastic Surgery Suicide Puts Spotlight on Beverly Hills Patients" Desperation ...

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This story first appeared in the July 4 issue of The Hollywood Reporter magazine.

Even before Sandra D"Auriol leaped to her death from a medical plaza rooftop around 10 a.m. on Wednesday, Jan. 22, Beverly Hills was traumatized. The 53-year-old Hong Kong-based jewelry designer, then still unidentified, had spent hours lingering at the edge of the building at 414 N. Camden Drive, a premier address for top cosmetic specialists. She was naked, her legs dangling over the precipice more than 150 feet in the air and only a few yards down the street from Bravo star Lisa Vanderpump"s restaurant Villa Blanca ("Very sad," Vanderpump tweeted that day, "terrible scene") and the offices of WME, where agents and assistants couldn"t peel their eyes away from their windows.

As time ticked by, and police and D"Auriol"s husband, Yan, a former L"Oreal executive, desperately begged her to come to her senses from atop the roof, dark chatter percolated through nearby physicians" suites. It soon was learned that the woman had undergone a 13-hour face-lift in that very same building the previous day by A-list plastic surgeon Dr. Brian Novack, whose discreet client list is said to include Demi Moore and Meg Ryan. After awakening earlier that morning in Novack"s 10th-floor office in an unexplained panic, she fought with a nurse and outran a security guard upstairs to the roof.

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"She"s probably jumping because she saw the bill," one neighboring staffer grimly observed to colleagues before D"Auriol leaped. (Novack is known for charging some of the highest rates in Beverly Hills, as much as $150,000 for a face-lift.) Speculative theories quickly circulated: that she"d taken her bandages off too soon and didn"t like what she saw, that she"d had a bad reaction to her medication, that she"d suffered an unrelated psychotic break.

Five months later, the cause of D"Auriol"s death remains subject to speculation. Although the Los Angeles County Coroner has listed it as "postoperation psychosis clinical," and D"Auriol"s family released a statement attesting that her "fall appears to be linked to a postoperative neurobehavioral disturbance" in which "the Sandra we knew and loved for her calm, positive disposition never regained consciousness," the details of what led to her suicide remain shrouded in doubt. The Beverly Hills Police Department has pursued an investigation into criminal negligence, and a malpractice suit appears imminent. Neither D"Auriol"s family nor Novack would discuss the incident with THR. Cases like these tend to be settled out of court, say lawyers, with the findings forever sealed.

Yet despite the informational vacuum, the incident -- caught on camera phones and uploaded to YouTube, where haunting footage of D"Auriol still can be seen -- continues to reverberate as a symbol of the strange, specialized and secretive aesthetic empire synonymous, perhaps second only to celebrity, with Beverly Hills. Despite its seemingly bizarre singularity, the events of Jan. 22 reflected trends both real (the ever-more-crucial-to-the-bottom-line importance of deep-pocketed international clientele) and perhaps implied (the mental woes of patients who arrive at LAX hoping that a procedure is the answer to what troubles them).

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Abroad, media outlets have latched on to the disturbing mystery of how the respected D"Auriol could meet such an ignominious end. In addition to her jade-oriented jewelry business, she had worked for Asprey, a supplier to the British royal family, and was an active philanthropist, co-founding the Nepal-based Child Welfare Scheme. Many reports noted that the D"Auriols had suffered devastating misfortune: Their 12-year-old son, Teo, one of three children, died in 2004 from a swimming accident on the final day of a family vacation in Bali.

But it is among the Beverly Hills plastic surgery community"s own patients and physicians -- most of the latter view Novack (whose record with the California Medical Board otherwise is unblemished) with a "could have been any of us" wariness -- that the story has resonated most powerfully. Was D"Auriol"s death a terrible fluke, or did it suggest something sinister about the way the industry works?

Beverly Hills, whose brand is glamour, possesses the highest density of flesh sculptors anywhere in the country. Seventy-nine doctors currently are listed on the American Society of Plastic Surgeons" roster for the city of 35,000. (Compare this with 47 for the entirety of the city of Los Angeles, population 3.9 million.) "It"s absolutely a substantial part of the business base here," says Alexander Stettinski, executive director of the local chamber of commerce. Their discreet upper-floor suites -- clustered, for the most part, in the town"s Golden Triangle commercial district -- overlook the passing pretty-people parade along a few choice blocks west of Rodeo Drive: Camden, Bedford, Brighton, Roxbury, Linden and Spalding.

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It"s been this way since the days when Marilyn Monroe would duck into the Bedford Drive suite of cosmetic surgery specialist Dr. Michael Gurdin during the 1950s and early "60s to fix her chin implant (made of carved cow cartilage in the days before silicone implants) and correct her broken nose. "This area used to be called Couch Canyon," because of all of the psychoanalysts in session, says Dr. Norman Leaf, who eventually took over Gurdin"s practice. "But when Prozac and such got started, they left and surgicenters took over."

The more than two dozen Beverly Hills plastic surgeons with whom THR spoke for this story describe a competitive but scrupulous realm, one inextricably bound to the global market. Some practices now draw as many as a third of their patients from beyond American borders, especially the Middle East (Saudi Arabia and the United Arab Emirates are tops), Asia (China, South Korea), Russia and the U.K.

Word of mouth is, as always, important -- especially in certain tightly knit cities. "Hong Kong and Singapore are small towns, at least in terms of their elite," says Dr. Marc Mani. A few of the most enterprising physicians, such as Mani and Dr. Jason Diamond, regularly fly to foreign capitals for brief stints to perform surgery to spread the word and drum up new business. But more often, it"s referral services and search engine-optimized websites that yield consultations. Observes Dr. Andrew Ordon, "Proof is that so many have created sites with multiple languages: Chinese, Russian, Arabic."

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For some media-savvy local doctors, however, what attracts the most clients is, fittingly, their own celebrity. Makeover and medical reality TV shows involving cosmetic procedures, in which being identified as a "Beverly Hills plastic surgeon" is the ultimate signifier of status and expertise, are distributed across the globe, often for years after they first air. They prove to be marketing gifts that keep on giving. Dr. Linda Li, who starred on E!"s Dr. 90210 for five seasons, says the show "made the biggest difference" for her. "Even though it stopped airing in 2008," she adds, "people still watch it around the world. It"s on Netflix!"

Yet the most considerable lure of all is the one least mentioned publicly by these physicians: the famous faces who have had work done in Beverly Hills operating rooms. "You hear about so many people over there -- the stars -- having cosmetic surgeries," says a 42-year-old housewife from Australia who saw Dr. Stuart Linder for corrective breast augmentation in 2011. "I thought, "Well, they"ve got to be good!" " A British executive, also 42, explains the appeal of going to doctors who work on celebrities. "They work on people who have a camera inches from their face," she says. "They have to look like perfection." To have the bags removed from under her eyes, she sought out Dr. Leslie Stevens after Sharon Osbourne identified him as her surgeon.

Such widely disseminated programs as Dr. 90210 and The Doctors have lifted the profiles not just of the particular doctors who appear on the shows but of anyone operating in Beverly Hills. "There"s this aura of Hollywood and a certain branding," says Dr. Robin T.W. Yuan of the local scene. "The perception is one thing that we live off of."

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If price is no object, the five-star Peninsula hotel, a mere scalpel"s toss from several prime medical buildings, has emerged as the go-to choice for out-of-towners, starting at $570 a night; the relatively more budget-minded tend to flock to the boutique Mosaic a block east.

The type of patients who come to Beverly Hills from overseas tend not to be affected by price, say doctors (who, among the A-list, can pull in annual incomes of up to the mid-single-digit millions). And they frequently pay in cash. Eye-lifts, nose jobs and vaginal tightening in Beverly Hills start these days in the $5,000 to $10,000 range, while face-lifts begin at $20,000. (Most popular still? Breast augmentation.) Full body-lifts -- the most expensive operation, an all-in-one procedure that reshapes the patient"s entire body: hips, thighs, buttocks, abdomen, breasts, back, etc. -- can top out at $250,000. "If I have a patient who has to ask about what the fees are," says Mani, "they probably need to go somewhere else."

One inviolable rule: Any procedure that involves a correction of someone else"s work will add to the price, likely sizably. "Revisions do cost more," says Dr. J. Gerald Minniti. "It has to do with the fact that it"s harder to fix a problem with scar tissue and the changes in the rest of the tissues."

Generally, Beverly Hills procedure requests run the gamut, regardless of geography, yet certain regional preferences predominate. Middle Easterners -- who, observes Mani, "tend to have more humps on the bridge of their nose" -- avail themselves of rhinoplasty more frequently than others. (Men, though, tend to "want to maintain their ethnicity," according to Ordon, while women "want a more stylized nose: I get a lot of Angelina Jolie.") Central and South Americans frequently are most interested in boosting their curves. "The Latinas like the J.Lo look," says Linder. Aside from well-known eyelid surgery, Asian clients often seek a rounder face via jaw work as well as calf reductions. "It"s very undesirable to have thick calves in Asia," says Rosenberg. "I thought I"d heard of everything."

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Yet most foreign clients travel to Beverly Hills for the same straightforward reason Angelenos visit their local plastic surgeons: They simply want to look rejuvenated. Face-lifts, tummy tucks and all of the other standard anti-gravity and back-in-time measures are the most common, as the sizable majority of patients are female and middle-aged, like D"Auriol. "A refresher, I like to call it," says Donna Wolfe, a luxury concierge with a firm called Plaza Travel who handles arrangements for Dr. Cat Begovic"s burgeoning international client list and who had her own eyes done last year. "I"m from L.A.; that"s what we do."

Says a 52-year-old South African female fashion merchandising executive who received a chin implant and an eye-lift from Diamond: "Everybody I know and work with -- including my kids -- say to me, "You look so refreshed and happy." No one has said, "What did you do?" The only part that I think was a little tough was -- you know when a dog has to wear a cone around their neck? I had to wear that cone around my neck for the first week. You get used to it, though. And it was worth it. You know what they say: Beauty is pain."

Although Dr. Novack"s prominent colleagues in Beverly Hills won"t speculate publicly about the D"Auriol incident, it"s clear they have been shaken by it. "It"s really, really tough," says one. "We live in a world where we don"t have all of the answers."

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They are, however, keen to talk, in light of her death, about what they see as the misunderstood challenges of their jobs. It stands to reason, and has been backed up by studies, that people who seek out plastic surgery suffer far higher than normal incidences of depression, anxiety, body dysmorphic disorder and other mental conditions. A 2007 report in the journal Annals of Plastic Surgery found that suicide was up to three times higher for women who have breast-augmentation surgery.

"We have found that about 20 percent of people coming in for a procedure are on some sort of psychiatric medication, mainly antidepressants," says Dr. David B. Sarwer, a professor of psychology at the University of Pennsylvania"s medical school and a leading researcher on the psychological dimensions of cosmetic procedures (the percentage of the general population on psychiatric medication is roughly the same 20 percent). Adds Dr. Garth Fisher, known in Beverly Hills for his lifts: "Probably a third, or at least a fifth, of the patients we see are on some kind of antidepressant. Although they are probably overprescribed."

Complicating matters is the fact that patients often are less than truthful about their medical histories. "When someone comes for a consultation, the interview is a two-way street," says Dr. Michael J. Groth, who specializes in eyelids and eyebrows. "They are interviewing you as a doctor, but you are also interviewing them as a potential patient, and there are red flags. For instance, if they deny having plastic surgery in the past, but you see incision lines. Or people who say they have chronic pain but don"t tell you the full extent of the pain medication they use, or claim it"s more for sleeping."

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Drug use, both prescription and illicit, is a particularly sensitive area. "Patients come in, and the night before they"ve been doing drugs, and they"ll say, "I don"t do that at all," " he says. "We don"t want to judge anybody, but patients lie and [when they are confronted], they say they’re worried that their surgeries would be canceled. That’s what they are concerned about! Not how those drugs would mix with the drugs they are being given during surgery.” Observes Francesca Camp, a veteran plastic surgery consultant and author of the forthcoming Do I Need It (And What If I Do)?: “Some of these patients are pros — they know what to say to [their doctors] to make themselves look stable and pass.”

Malpractice attorney Stephen Fraser, who defended Michael Jackson‘s former dermatologist Arnold Klein in a 2004 suit brought by producer Irena Medavoy over Botox and migraines, notes that doctors are easily fooled by dishonest patients. “One of the biggest difficulties that these [elective-surgery] physicians have is dealing with patients whom they aren’t seeing routinely,” he says. ” ‘Where else did this patient get medication?’ There’s only so much you can do in terms of inquiry. Then you have to rely on the patient’s veracity. A lot of times patients who are taking Percocet or Valium are getting them from multiple providers.” Fraser adds: “It places an inordinate burden on the surgeon.”

The results can be lethal when caregivers find themselves caught off-guard by reactions to drugs used during a procedure (like anesthesia) or afterward (pain-suppression medication). One hypothesis for D’Auriol’s behavior that circulated widely in the media and among physicians is that it was an extreme case of emergence delirium, a temporary postoperative state linked to anesthesia that affects roughly 5 percent of patients. D’Auriol’s brother-in-law Guy told the South China Morning Post on Feb. 3 that the family is concerned about the side effects and impact of anesthesia: “We can only hope this leads to better, less-risky drugs.”

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Yet one veteran anesthesiologist tells THR that unrelated drugs mixing with anesthesia itself can cause delirium. “You put the person to sleep assuming they told you the correct story,” says this doctor. “Some people f– around with their drugs at home, oftentimes these powerful benzos like Xanax and Valium, and they don’t believe in giving a truthful history. So they wake up with a lot of medicine in their system, which can create a cascade effect with what their anesthesiologist gave them for surgery.”

Aside from undisclosed drug use, Beverly Hills cosmetic surgeons say their biggest issues with patients often have to do with unrealistic expectations. “Most disappointment with surgery isn’t a bad result,” says Groth. “It’s an unmet expectation. They wanted to look like their high school photograph. Now they look better — but not that much better.” Adds Fisher: “It’s all about managing expectations. People who come in saying ‘perfect’ too much worry me.”

The worst issues arise from those who suffer from body dysmorphic disorder, or BDD, which manifests itself as excessive, obsessively negative thoughts about perceived, often minor physical flaws. Research has shown that while less than 5 percent of cosmetic surgery patients suffer from BDD, about three-quarters of individuals with BDD seek out cosmetic surgery. “BDD is troublesome,” says Dr. William Dzwierzynski, a professor of plastic surgery at the Medical College of Wisconsin. “There’s a high incidence of suicide and violence toward others, including the surgeon. These are people who will never be satisfied with their body and the work.”

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Dr. Andrew Frankel, a Beverly Hills rhinoplasty specialist, notes that BDD “manifests itself in several different amplitudes,” making it hard to diagnose. “You can see it coming from a mile away, or it can be very subtle,” he says. “Every single patient coming for elective work is really coming for a psychological boost.”

Cosmetic practitioners ostensibly screen for BDD and other psychological issues with brief, standardized questionnaires. “But do most plastic surgeons even use them? No,” says Dzwierzynski. “They use the gestalt feeling: ‘This patient rubs me wrong.’ “

It may be the pressures of a competitive marketplace, or perhaps it’s just the nature of a specialty that caters to vanity, but plastic surgeons often are loath to probe deeply into the mental health of their patients for fear of, as Dzwierzynski puts it, “scaring away” their would-be clientele.

“Ideally you’d send everyone to a psychological evaluation,” says Dr. Raj Kanodia, another Beverly Hills physician known for his skill sculpting noses. “But in reality, it’s not practical, not feasible. The patient will say, ‘Why should I go?’ ” Concurs Frankel: “They’ll say, ‘Who are you? You’re just a plastic surgeon. Who are you to say I need a therapist?’ “

This response is unfortunate, maintains Manhattan-based psychologist Vivian Diller, author of Face It: What Women Really Feel as Their Looks Change and What to Do About It. “I would advocate for an automatic screening by someone skilled in the psychological makeup of the client coming in for the surgery because it’s such a tricky line, particularly since we know that plastic surgery can become repetitive,” she says. “We’re still just beginning to become aware of the consequences of it: Sometimes people actually miss the face that they dreamed of changing — that was also your family’s nose; your child’s, your mother’s — and they can’t admit it because once it’s done, it’s done.”

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Given the myriad, messy challenges at play, it would make sense if Beverly Hills surgeons constantly were fighting off lawsuits. But in fact, suits are rare. California state law caps compensation for noneconomic damages (pain and suffering, emotional distress) at a mere $250,000; given that it easily can cost $100,000 to bring a case to trial, the risk/reward math just isn’t there.

“They’re extraordinarily expensive to litigate, and cosmetic surgery cases are generally disfavored by juries,” explains attorney William H. Newkirk. Juries tend not to be sympathetic to someone who elected to have plastic surgery. “It just becomes very, very difficult to prevail on these cases,” adds Newkirk, “and when you do, you can’t make enough money to make it worthwhile to do it.”

Except, that is, when concrete errors can be proved to have led to devastating results. Attorney Eran Lagstein says he’s juggling a pair of such cases right now. One is a woman whose facial-filling injections around her eyes caused nerve damage. The other involves a perforated colon: “I just got a call from a man whose wife got a tummy tuck a few days ago, and now she’s fighting for her life. Based on what I’m hearing, she became septic — bacteria found its way into her blood. Maybe she wasn’t properly sterilized. Now she’s looking at, possibly, multisystem organ failure.”

D’Auriol’s death likely will remain a quintessential L.A. noir sensation: the naked and disoriented blonde, fresh from a face-lift, jumping off a Beverly Hills high-rise in broad daylight to bystanders’ horror and disbelief. After all, the superficial specifics are shorn of any meaningful context; nobody will ever know what was going through her mind that day. Yet, just like every cosmetic surgery patient, she no doubt had her reasons — complicated, subtle and even profound reasons — to undergo such a procedure in the first place, whatever they might have been. Only she knew the true shape and merit of the risk she took.

On Feb. 13, after 1,000 friends and family members packed St. John’s Cathedral in Hong Kong to pay their respects to D’Auriol (all of them dressed in bright colors to comprise a symbolic colorful bouquet of flowers in lieu of real ones because she loathed waste), her wake was held at the throwback-elegant China Club on the top three floors of the old Bank of China building in the city’s financial district. There, the mourners were handed copies of a speech D’Auriol had given to a local YWCA chapter in 2012, in which she talked about the pain and resolution of accepting her son Teo’s death eight years earlier in Bali.

“I know now that if I had nothing and nobody, I would still find life beautiful because my happiness does not come to me through stuff and working on myself,” she said at the time. “It is the happiness that I have when I share a connection with a human heart.” The speech went on, “This life passes so quickly, and we spend so much of it creating pictures of what we think life should look like. The only thing that really stays after we are gone is the kindness.”

Karen Chu in Hong Kong contributed to this report.

Plastic Surgery Suicide Puts Spotlight on Beverly Hills Patients" Desperation ...