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Here is something to consider the next time you consider undergoing plastic surgery: plastic surgery centers that have failed state standards are still allowed to accept patients under strange patchwork rules in place in California.

Take Maria Garcia, who went in to have outpatient plastic surgery in 2008. By day’s end, she had bled to death from a puncture wound. What Maria didn’t know was that the widely advertised plastic surgery center that she went to was only open 90 days before her surgery took place. In addition, her doctor was under investigation by the California Medical Board. She also did not know that Hills Surgical Institute failed to meet the state’s requirements for surgical centers that use general anesthesia, according to her family’s attorney, Jin Lew.

While California has a billion-dollar-a-year cosmetic surgery industry, plastic surgeons and the centers that they operate are governed by a strange conglomeration of rules loosely enforced by private "accreditation companies". California stopped licensing surgery centers owned at least partially by an accredited doctor in 2007 after a doctor successfully challenged the state’s regulatory authority in court. Since then, the number of plastic surgery centers that are state-licensed has dropped tremendously: only 45 surgical centers are now state-licensed, compared with about 480 before the law changed. Furthermore, unlike state regulators, accrediting groups do not fine surgery center owners or doctors who violate rules on patient safety, although they can pull a center’s accreditation. Just two years ago, California safety lobbyists started pushing for better patient safety at cosmetic surgery centers. California isn’t alone, either: two years ago, Florida passed a law designed to educate patients about their doctor’s credentials and in Ontario, Canada officials are increasing scrutiny after the death of a Toronto woman who received liposuction from a general practitioner.

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