Deaths of Americans After Cosmetic Surgery in the Dominican Republic, 2009–2022

Traveling abroad for medical care — medical tourism — is increasingly common among Americans, drawn by lower costs and shorter waits. The Dominican Republic is a popular destination for cosmetic surgery: it is close, has tourism infrastructure, and some of its doctors advertise in the United States. CDC has documented complications among Americans after cosmetic surgery there since 2003. Most reported problems have been infections; deaths have rarely been reported. That changed in 2019.

A rise in deaths

Since 2009, the U.S. Embassy's consular section in the Dominican Republic has recorded deaths of U.S. citizens linked to cosmetic surgery, using reports from families, funeral homes and the country's National Institute of Forensic Sciences, which autopsies every foreign citizen who dies there.

• 93 U.S. citizens died after cosmetic surgery in the Dominican Republic from 2009 to 2022. All but one were women; the average age was 40 (range 19–69).
• From 2009 to 2018, deaths averaged 4.1 a year (1–8 a year).
• They jumped to 12 in 2019 and 17 in 2020, and averaged 13.0 a year in 2019–2022.

Cosmetic surgery–related deaths of U.S. citizens in the Dominican Republic, by year. Credit: Centers for Disease Control and Prevention.

The embassy alerted CDC, which investigated with the Dominican Republic Ministry of Health. A case was a U.S. citizen who died in the Dominican Republic within 3 weeks of cosmetic surgery — procedures such as breast surgery, abdominoplasty, liposuction and gluteal augmentation.

What the records showed

Medical records were available for 24 of the 29 deaths in 2019–2020, all women, average age 41.

Every patient had at least two procedures in one operation, 18 had three or more, and the average was three. 14 (58%) died within 24 hours of surgery; the average was 2.8 days (range 0–18). Nine clinics were involved, two of them in two or more deaths.

Causes of death, from 20 autopsy reports:

• Fat embolism: 11 (55%). Every one of these patients had liposuction and gluteal fat transfer, in which fat is taken from the body and injected into the buttocks.
• Pulmonary venous thromboembolism: 7 (35%).
• One death from hemorrhagic shock and one from sepsis after an intestinal perforation.

In all, 18 of the 20 autopsied deaths (90%) were due to emboli.

Preventable risks

Nearly all patients had risk factors for clots:

Previously published recommendations advise against injecting fat into the deep muscle layers of the buttocks. Assessing each patient's clot risk before surgery — with validated tools such as the Caprini score — should be standard, guiding measures such as walking soon after surgery, compression devices and anticlotting medicines.

What has changed

• In 2019, the Ministry of Health issued safety and quality recommendations for cosmetic surgeons: training and licensing requirements, heart and lung evaluations before surgery, and no more than two major procedures in one operation. After CDC shared preliminary findings, it distributed the guidelines, made monitoring visits to 77 facilities, certified infection control committees at high-volume centers, and created a commission, including the Dominican Society of Plastic Surgery, to review complications and deaths and recommend sanctions.
• The U.S. State Department updated the embassy's Medical Tourism and Elective Surgery advisory with steps to lower risk, including buying international travel insurance that covers medical evacuation.

Limitations

• There are no reliable counts of how many Americans have cosmetic surgery in the Dominican Republic, so the risk of death can't be calculated.
• Only deaths reported to the embassy were counted; complications recognized after patients returned home were missed.
• Deaths are rare; the report doesn't cover more common problems like infections.

If you're considering surgery abroad

• Talk with your regular health care provider about your own risk of complications and how to reduce it.
• See a travel medicine specialist at least a month before you go.
• Air travel and surgery each raise the risk of blood clots — allow enough time between flying and surgery.

Sources

Based on Hudson M, Matos JA, Alvarez B, et al., "Deaths of U.S. Citizens Undergoing Cosmetic Surgery — Dominican Republic, 2009–2022," Morbidity and Mortality Weekly Report 73(3), Centers for Disease Control and Prevention; a work of the United States government in the public domain. Original report.