Before and After 

Imagine: You are feeling less than satisfied with the effects of age on your once-flawless complexion. You’ve acquired several large brown spots, or maybe there are a few wrinkles that have crept around your eyes, as if overnight. Every time you look in the mirror, those imperfections seem to be all that you see. One day, while flipping through a glossy magazine, full-page advertisements touting cosmetic laser surgery start jumping out at you. The “Before” and “After” pictures are dramatic. Colorful and carefully scripted, the ads promise a more beautiful you with just one simple outpatient procedure. You begin seriously considering the possibilities for yourself. Searching through the yellow pages under “Plastic Surgeons,” you find even more advertisements and listings that pretty much sound all the same. One is probably as good as another, right?

Fast-forward. The doctor is taking off your bandages for the first time. You expect some swelling as you look in the mirror. But this is worse. Something is terribly wrong. You hope it’s all a bad dream, but you soon learn that your face and life have been transformed into a living nightmare. This Twilight Zone scenario is reality for at least two former patients who are suing Dr. L. Douglas Israelson, who is licensed to practice dentistry in Utah but who has broadened his practice to include, according to his website, wrinkle removal, acne scar treatments, age spots and facial pigmentation, excess eye tissue, bags under eyes, mini face-lifts, lip augmentation and blue peel. But Israelson does not hold an M.D. degree and is not board-certified as a plastic surgeon.

Gladys Hale went to Israelson two years ago to have several dark pigmentation spots removed from her face by laser surgery. Hale still has the spots, but now is also disfigured, with scar tissue running like tracks and reaching from her right ear and cheek, down her neck to her chest. Her face, lips, and neck have very limited mobility and the frequent pain causes her to wake from sleep, according to a lawsuit filed in 3rd District Court. Once a beautiful, active and social woman, Hale now suffers from physical pain and self-conscious embarrassment that have pushed her toward reclusivness. Her ability to continue in her profession as a schoolteacher is impeded by the unbearable difficulty of standing before curious, questioning children.

Hale returned to Israelson. “He said, ‘Don’t worry, it’s getting better. Do nothing. That’s the best way,’” she recalls. “After quite a while, later on, I decided to reach out myself and went to my own physician. He diagnosed an infection and recommended I go back to Israelson for treatment.”

As the infection worsened, the skin on Hale’s face bulged, causing her mouth, nose and eyes to be pulled downward until she could no longer close her eyes, the suit alleges. She was enduring excruciating pain as Israelson continued treating her. Not seeing or feeling any improvement, she told him in her desperation that they should ask for another doctor’s help. “I said, ‘We can’t do this by ourselves,’” she remembers. “So he recommended I see a dermatologist. After that, I went to Dr. Thomas, a plastic surgeon.”

Dr. David S. Thomas explains that when a laser goes too deep, the tissue takes longer to heal and is more prone to infection. The infection causes further tissue to be lost. Thomas is adamant that only board-certified plastic surgeons have the proper training to perform laser surgery. “Oral surgeons think they’re super dentists and laser surgery is going to be easy,” he says. “The point is, without proper training, how do they know if they’ve gone too deep? If there are complications, the problems can only be mitigated if you’re trained correctly.”

Thomas is disturbed. “What happened to Gladys is remarkable. Some things can be restored, but when it’s that severe, it can never be completely restored,” he says. “In my opinion, laser wasn’t even the correct treatment for her condition.”

A second plastic surgeon is now treating another former patient of Israelson’s, whose life is also forever changed. Nineteen-year-old Elisha Mills came to Israelson with a congenital small ear, called microtia. Without giving her any other options, he amputated her ear in his office, according to a suit filed in 3rd District Court. From the preoperative photos, the plastic surgeon says that her ear could have been reconstructed using parts of the small ear and her own tissues. “In such cases, ear reconstruction using a patient’s own tissues, including rib cartilage, is the procedure of choice nationwide,” he explained. “A patient must always be given the options so that she can make an informed decision.”

Although Israelson is not trained to reconstruct ears and does not have hospital privileges in any hospital to operate, he then inserted titanium dental implants, which are intended to be used in the jaw for tooth buildup, and screwed them into her skull, sticking out through the skin. His plan was then to attach a prosthetic ear to the pins, according to the lawsuit.

“When a foreign body, which titanium is, goes through the skin, it is a setup for infection. This is exactly what happened. She had ongoing chronic infection and bony erosion,” says Elisha’s plastic surgeon. “Should a man with a dental degree be operating on a patient’s ear? What is the scope of dentistry? A decision was made for this patient without providing her the knowledge to make a knowledgeable decision and left her with no ear, extensive scarring and charged her exorbitantly for the damage.”

Elisha says that Israelson told her that prosthetics was the No. 1 choice for her condition. The entire charge for his handiwork was $9,750. After insurance papers had been submitted for preapproval, she was called one day unexpectedly and told to come in for the surgery within three hours. “They said the insurance had approved the surgery and didn’t even ask if I’d eaten that morning,” she remembers. “Now I know that the insurance didn’t pay because I’m getting the bill.”

After surgery, the pins sticking out of Mills’ head became infected almost immediately, and she also had to deal with the effect that temperature and noise had on them, according to the lawsuit. Cold made the pins contract, causing headaches. Heat caused them to expand, making the infection worse. Too much or any loud noise made the pins vibrate to the point that she had to have a private office at work. “After three months, Israelson sent me to a dental lab to get my prosthetic ear made. That was a surprise, because I thought I would get it through him,” she says.

Perhaps even more surprising was that her prosthetic ear wouldn’t be made to match her natural ear.

“So the lab technician looked at me and said he had three women in the lab and I could choose one of them to have a right ear molded from.” Mills was then told that when her ear was made she couldn’t go out in the sun or swim with it. She also learned for the first time that it would have to be replaced every three years at $5,000 each time. She fled from the lab in tears and began looking for an attorney.

“Then one day in the car, it just blew,” she says. “It was like I’d been shot in the head. Blood was all over the car.”

When Mills finally went to a real plastic surgeon on the advice of her attorney, the infection had begun to move toward her brain, becoming potentially life-threatening. “It’s devastating. I looked a lot more normal before and I had some hearing. Now no one knows yet whether I’ll regain any hearing,” she says. “I thought he had an M.D. degree. I didn’t know he was a dentist. I went to surgery under false pretenses.”

To reconstruct an acceptable ear for Mills, her plastic surgeon will have to do a series of operations in which he will use skin grafts from her neck, remove a floating rib, take cartilage from other ribs and possibly take a bone graft from her hip. An ear specialist will reconstruct the eardrum.

Mills’ trauma is disturbing to her new surgeon. “It bothers you to see something like this. A doctor must be objective about patients. However, someone robbed this girl of her chance for her own ear.”

Israelson’s full-page advertisements are impossible to miss inside the pages of the slick Salt Lake magazine. In those ads, there is no indication of his being an oral surgeon, going so far as to omit DMD (Doctor of Medical Dentistry) after his name. His claim of being “board-certified” would lead one to think he is board-certified by the American Board of Plastic Surgeons. However, he is not. In the Yellow Pages, a half-page color ad can be found under the plastic surgeons section. In the dental section, he only has a listing and a one-inch square display ad under the dental specialty of oral surgery. The white pages have Israelson offering to do face-lifts.

The windows at Israelson’s Fort Union-area office bear titles carrying the full weight of the state: Utah Laser Center. Utah Oral Surgery. Inside, pamphlets and tabletop signs share space with magazines. Over half of the pamphlets and all of the signs advertise cosmetic procedures from laser surgery to Botox injections. A large conference room boasts a wall covered with diplomas and plaques accumulated over the span of a very long career. Several were given for one-day courses.

Israelson graduated from dental school in 1973 and did his postgraduate and residency in oral surgery from 1973-76. He is board-certified by the American Board of Oral and Maxillofacial Surgery and is a fellow of the American Society of Laser Surgery. He does not hold a medical degree. He is not certified by the American Board of Plastic Surgery. He is not a member of the American Society of Plastic and Reconstructive Surgeons, nor is he a member of the Utah State Plastic Surgery Society.

“Laser surgery seems like a natural that interfaces with what I’ve done over the years. In that area, my expertise is strong,” Israelson said in a City Weekly interview. “Oral surgery is the lost child between medical and dental. Cosmetic surgery is a bridge between the two and that’s why it works so well.”

In a typical day, Israelson’s appointment book consists of 50 percent dental patients and 50 percent cosmetic surgery patients. He says the number of patients seeking laser surgery jumped almost overnight.

When asked to comment on criticisms of dentists overextending their reach into plastic surgery and to comment on his former patients with negative postoperative results—specifically Gladys Hale and Elisha Mills—Israelson refused comment, saying he was offended. “I don’t need to defend myself or the scope of my practice. Everyone becomes involved in postoperative results that may not be what is anticipated,” he says. “I consider myself a professional.”

But according to Israelson’s website, www.utahlasercenter.com, risks from cosmetic surgery are practically nil: “Cosmetic facial surgery has been available for many years, but has always carried the shadow of pain, complications and significant risks. Now with the advent of cosmetic laser surgery, these fears and risks have been nearly completely eliminated. …”

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In 1998, The Salt Lake Tribune featured Israelson in an article that followed a patient through the process of laser resurfacing of her face. Israelson couldn’t have paid for better advertising. The story appears on his website, but the article does not mention his credentials or lack of them. The Tribune story surprisingly does not explain to readers that he does not hold a medical degree or that he is not a board-certified plastic surgeon.

Within the last decade, the number of patients undergoing plastic surgery has tripled. No longer considered a decadent indulgence of the rich and famous, plastic surgery is now a feasible alternative for average middle-class Americans, who are flocking to improve or change their appearances through the wonders of modern medicine.

Plastic surgery is both a science within the medical scope and an art as a sculpting of the human form. To become a plastic surgeon, it takes four years of medical school, a one-year internship, up to five years of surgical residency and three years of plastic surgery training. The surgeon must take board exams, both written and oral, before a board of peers in the chosen specialty. Then there are yearly continuing education requirements to fill as well as registration with the state, licensure and certification with several certifying boards. Once a surgeon is board-certified, each hospital’s credentials committee reviews the doctor’s qualifications before granting privileges.

The blurring of oral surgery, which is a dental specialty, and the medical specialty of plastic surgery, especially as practiced in Utah, evolved through a series of national and local changes and took place over a period of time, with a little help from laser technology. Dentists began using laser technology for procedures within the mouth that previously required a scalpel. With a laser, dentists are able to minimize bleeding and eliminate sutures. Other types of laser procedures which dentists employ are bleaching the teeth whiter and removal of some dental cavities.

Although most oral surgery is performed in the dental office, there are the occasional times where oral surgery requires patient hospitalization. Fifteen years ago, dental schools throughout the country began requiring graduates specializing in oral surgery to also obtain a medical degree. According to Monty Thompson, executive director for the Utah Dental Association, “A medical degree became a requirement for most oral surgeons because oral surgeons were restricted from hospital privileges.” Thompson concedes that only dentists who graduated with and since the medical degree requirement have the ability to expand their practices. “Dentists before that—no,” he says. “The older ones haven’t had the training.”

In Utah, the Legislature expanded the definition of the “Practice of Dentistry” to include “Adjacent hard and soft tissues and structures in the maxillofacial (lips and jaw) region.” Before, hard (bone) and soft tissues were strictly limited to the oral cavity. This ambiguous definition from medically uneducated lawmakers gave dentists a very broad brush if so inclined.

The Utah Division of Occupational and Professional Licensing (DOPL) is a division of the Department of Commerce, the agency that oversees the competency and licensure of dentists, physicians and most other healthcare professions. In 2002, DOPL licensed more than 2,000 dentists and 6,700 physicians. With only 20 to 25 investigators, 4,500 complaints were looked into during 2001. (Figures for complaints in 2002 were not available.) Scott Thompson, Public Information Officer for the Department of Commerce, is confident the DOPL is doing its best in the public’s interest. “Our charge is to protect the public welfare,” he says. “We have no control over quality or craftsmanship of a professional, but, as for frequency of complaints, it’s a judgment call.”

Any action against a healthcare professional must first be filed with DOPL in the form of a “Notice of Claim” before it can be taken to a court of law. A three-person hearing is convened before a DOPL pre-litigation panel, which consists of one attorney, one layman and one professional of the same specialty. Nothing said during the hearing is admissible later in court and the decision (whether a case is meritorious) is non-binding. Since the hearing is non-binding, the professional can lie and manipulate the facts for a favorable ruling.

If a DOPL panel decides that a case is meritorious, a professional can simply say that he refuses to pay anyway. It’s a non-binding hearing, after all. Then the plaintiff must file a suit to pursue any claim. If DOPL decides the case is meritorious, the professional can settle (often requiring the plaintiff’s silence) and avoid potential negative publicity. Malpractice insurance covers the cost of the attorney for the professional as well as any settlement amount paid to the plaintiff.

Attorney Scott Ray, however, sees DOPL as a useless exercise that doesn’t protect the public. He represented medical malpractice insurance companies for 17 years and is now on the opposite side, representing plaintiffs. “Does it really matter what happens in a DOPL case? The answer is no,” he says. “Why have we made special procedures that cost the public more money and serves no good?”

Many physicians disagree, however, pointing out that 80 percent of all cases brought before DOPL are found to be non-meritorious, thereby eliminating numerous cases that would otherwise be jamming the courts. DOPL does not investigate each complaint it receives. “We take every complaint on a case-by-case basis,” says Thompson. Some translate that to mean that investigations and disciplinary action by DOPL is completely arbitrary.

In the case of dentists, the profession as a whole opted out of DOPL pre-litigation hearings. Because Israelson is a dentist and not a licensed plastic surgeon, he is not subject to DOPL hearings.

Gladys Hale’s attorney, Tim Houpt, filed a complaint against Israelson with DOPL, but division officials concluded that there was no basis for disciplinary action partly because Hale was informed of possible complications involved with surgery. Further, according to the DOPL Professional Conduct Unit, “There are no guarantees in the healing arts and hundreds of success stories are often followed by a tragedy … without a pattern of negligence sufficient to establish gross negligence, the division has no authority to act.”

Through the Government Records Access and Management Act (GRAMA), City Weekly requested from DOPL all records of investigations and complaints against Israelson. The request was denied, DOPL explaining that, “Any complaints or investigations that do not result in a disciplinary action are classified as protected records.”

The only record DOPL released was concerning an incident in 1988 in which Israelson performed surgery on one of his own employees, removing a bone spur from her toe. When the employee filed an insurance claim, the insurance company notified DOPL, saying they were denying her claim on the basis that Israelson was “not licensed to perform surgery outside of the oral cavity.” The record notes that it “did not occur” to Israelson “that his conduct was improper.”

In conclusion, the record shows that DOPL reprimanded Israelson by ordering him to “practice only within the proper scope for which he is licensed” and “duly comply with those statutes and rules, which govern the practice of dentistry and subsequently abstain from any unauthorized practice of medicine.” Gladys Hale and Elisha Mills, no doubt, wish that had been posted on his website as well.