Tears fall down Deyanira Polledo's face as she gently opens her sage paper gown. Furious red scars rip through the skin around her nipples, the left of which resembles a decayed mushroom molding off its stem. Slashing wounds, pink and raw, carve deep into the flesh under her breasts.

On March 19, Polledo walked into one of the ubiquitous cosmetic-surgery centers in Miami to have her breasts lifted and augmented with saline implants. All her friends—economy be damned—were doing it; the price here, at this dark office blasting Spanish telenovelas, was right. She never laid eyes on her doctor—who, she would later discover, holds a medical degree from Cuba, did only a one-year internship in this country, and has no board certification—until two minutes before he sliced her open. Even then, he didn't reveal his name. "I was scared, but I stayed," says Polledo. "Something in my heart told me to get out, but then I thought about the money I would give up." Seven thousand dollars—nonrefundable—had already been charged to her MasterCard.

Four days later, her nipples turned black. Her breasts were burning, flaming red. She hastened back to the squat concrete building covered in blue advertising banners, assuming the doctor would be as alarmed as she was. But he refused to see her. The clinic's owner, who is not a physician, handed over a prescription for antibiotics and sent her away. Three days after that, Polledo was rushed to the emergency room with a 107.5-degree fever from a raging infection devouring the flesh behind her implants. Her anonymous doctor had severed the arteries pumping blood to her nipples. She lay in the hospital for a month—unable to work or make payments on her home—with an IV feeding powerful drugs straight to her heart. Then she came to the office of Dr. Albert Gallerani, a board-certified plastic surgeon, who is treating her pro bono.

As Polledo gently closes the robe over her butchered chest, Gallerani returns from the next room, where he has been dissevering dead tissue from inside the abdomen of Lissette Pita, Polledo's friend who was also nearly killed getting her tummy tucked at the same place by a different doctor—who used unsanitary instruments and no gloves. There was so much necrotic tissue—which was on the verge of spreading throughout Pita's entire body and killing her—that Gallerani, having removed all the remaining fat, can fit two entire fists into the now-empty cavity just below her belly button.

"It's negligence, is what it is," says Gallerani, who spends long hours fixing botched surgeries done by unqualified practitioners. "Every week we see women who have gone to chop shops," says Maryann Boger, the manager of Gallerani's practice. "Women looking for the bargain, the deal."

Polledo's lawyer, Spencer Aronfeld—the go-to guy in Florida for cosmetic surgery gone wrong—turns away at least five women like Polledo and Pita every day. Because juries are reluctant to convict doctors in general and view these women as complicit in their injuries since they elected to have the procedures, winning a settlement—from a doctor who may not even have insurance—isn't easy.

These dubious practices have only been intensified by the faltering economy. Never before has there been such a tantalizing promise of eternal youth, with today's ready roster of tools to fill, tuck, and suction every imperfection. But never before have the risks been greater. Beauty-conscious women, once flush with extra cash in the glory days of a soaring Dow, have become hooked on pricey maintenance that they can now ill-afford. Doctors, reeling from declining insurance reimbursements for their medical services, are now recklessly offering discount aesthetic tweaks for which they have no training. It is in this unregulated world, where greedy practitioners prey on frantic women, that Polledo, a 37-year-old mother of three, lost her job and her house, while allowing her breasts to be mutilated.

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Last May, Carla Mainella, a 47-year-old Hollywood, FL, woman with stubborn post-baby fat congealed around her waist and upper thighs, had no reason to suspect that the doctor she picked to administer SmartLipo with Vaser—a procedure that combines two laser techniques to melt adipose tissue (which is then suctioned out with thin cannulas) and sculpt the skin—was anything but highly trained. The website for his wife's medi-spa, out of which he operates, was very enticing, brimming with pictures of the doctor surrounded by beaming, buxom Miami Dolphins cheerleaders; furthermore, Sound Surgical Technologies, the company that manufactures the Vaser Lipo machine, had listed him on their site. Mainella thought it was curious that her three afternoon appointments were delayed until late evening—one session lasted until 4 a.m.—but she was so delirious from the Valium they gave her when she walked through the door (and which she was still feeling the buzz from when she drove herself home), she stayed. "I call it the Horror Clinic," she says today, recovering in Italy from third-degree burns on her inner thighs, stomach, and back; the nerve and muscle damage in her legs may well be permanent. "I was only a little bit fat—I'd worked out my whole life. Now my body is destroyed," she says. Mainella, who runs a high-end Italian import-export business and owns a real estate company, is devastated that she let herself be victimized by someone with no expertise. It was only after she contacted a lawyer that she found out the doctor was certified solely in internal medicine with a specialty in pulmonary disease, and had settled a wrongful-death suit for $240,000 just one month before her procedure.

"Any medical doctor can practice cosmetic surgery—they don't have to specialize in it," says attorney Aronfeld. "We see gynecologists and pediatricians doing plastic surgery. An EMT or cardiologist could do Botox injections." Because Florida (as well as several other states) does not require doctors to carry malpractice insurance—and the Homestead Exemption protects their homes from collection on liability settlements—"it's really the perfect place for the less scrupulous medical provider to come and take advantage." And it's not just unlicensed foreign doctors crossing the border. "It's nice Jewish guys you'd want to introduce to your daughter who are taking advantage of the situation. They're in it for the money, thinking, Hey, it's legal. Why not? The danger now is the crossover—when your friendly neighborhood orthopedic surgeon decides he's going to do face-lifts."

Even dentists are getting in on the action. Board-certified dermatologist Dr. Roy Geronemus, director of the Laser & Skin Surgery Center of New York, was shocked to receive a notice from his own dentist saying that he offers Botox. "I found a new dentist," says Geronemus. "He ought to stick to what he's trained in."

"It's becoming very popular with them right now," says Dr. Louis Malcmacher, a general dentist from Ohio who travels the country training others to inject the substances, citing that it's now legal in at least 22 states for dentists to inject wrinkle-treating neurotoxin and dermal fillers. Calling from the Courtyard by Marriott at LaGuardia Airport, where he's just taught a course in Botox to 20 of his colleagues, he dismisses the polemic as a mere turf war, with core practitioners trying to keep all the money in their own pockets. Dentists are born injectors, he says. And anyway, "15 percent of Allergan's sales of Botox are going to OB/GYNs—now what the heck are they doing in the facial area?" he adds with a laugh. (Allergan says that it does not track sales by specialty.) Malcmacher markets his sold-out classes on his website ("Learn to produce up to $3000 per hour with these nonsurgical techniques") and admits he started injecting to satisfy his wife's penchant for the services. "Why should I send her to someone else, for crying out loud?" he says. It was easy not to: Allergan will teach even nonphysicians how to shoot its intramuscular toxin. (A spokeswoman for Allergan stresses that although they teach physician assistants and nurses, the company sells its products only to physicians.)

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"They don't care," says Boger from Gallerani's office, referring to how easy drug and medical device companies have made it for doctors to perform procedures outside their specialties. "The Vaser salesperson—who is not even a medical rep—comes in and says in six months you can make this much money; he trains the doctor in the afternoon, leaves him with a certificate, and then the doctor's on his own. These companies are out for the profit." (Vaser confirms their sales reps don't have medical training, but says registered nurses perform the actual training once a device is purchased.) Unqualified practitioners need not even jump through those hoops: Internet training services, such as Future Aesthetic Service Training, offer online classes 24 hours a day. (Its $695 two-hour Botox Basics class is "for medical professionals looking for new income streams," according to its website.) Laser devices are easily acquired on the unregulated secondhand market—eBay is rife with them—no training offered.

While most women unwittingly fall prey to unqualified doctors, some actually seek them out. After one Beverly Hills plastic surgeon asked Kanye West's mother, Donda, to undergo a medical clearance test before proceeding with a tummy tuck and breast reduction (standard procedure for patients over 50), she didn't, and found another doctor, Jan Adams. The day after her surgery, West died of heart disease and multiple postsurgical complications. Adams, who was not board-certified, at the time had multiple DUI-related arrests and at least four malpractice suits against him. (In February, he was sentenced to a year in jail for his most recent DUI; in April, he surrendered his medical license.)

A shocking number of women also check their good sense at the door when irresistible convenience is on offer. Board-certified L.A.-based dermatologist Dr. Jessica Wu says she just saw a patient—a young California yoga instructor and mother of four—who couldn't resist her family doctor's drive-by Botox offer when she was in for her kids' checkups. He offered her a discount, and, well, she was there. When she suddenly lost her vision a few weeks later, she rushed to the emergency room, thinking she was having a stroke. Wu says it was a temporary reaction to a faulty procedure. "People do these things because they think Botox is Botox is Botox, filler is filler is filler, no matter where you get it done," Wu says. "But you have to be careful. It's kind of scary out there now."

Watered-down or contaminated Botox, the reuse of liposuction tubing with multiple patients—nothing is off-limits in this tight market. Yet another problem is the infiltration of cheap, non-FDA-approved drugs traded on an oversaturated black market. General practitioner Dr. Jerome Lentini was recently sentenced to 18 months in the Federal Correctional Institution in Sheridan, OR, for injecting patients with research-grade drugs from China that he bought online. "I know that some of my colleagues are purchasing from these companies because it's cheaper than going through legitimate channels," says Wu. "But how do you really know what you're getting? In China, they've counterfeited Botox and made the labels to look identical." In March, Dr. Douglas Halliday, an ear, nose, and throat doctor from East Syracuse, NY, was found by his state's Board of Medical Conduct to have injected 12 patients with an unapproved botulinum neurotoxin labeled "For research purposes only—not for human use" from a company in Arizona. (He was fined and put on probation but is still practicing.) Dr. Gayle Rothenberg, an anesthesiologist highly regarded in the cosmetic field in Houston, was charged with using the same bargain knockoff on more than 170 patients, which allegedly resulted in over $98,000 in profits. Her subsequent conviction was reversed on appeal, and a new trial is scheduled for next month. At least two of her patients claim they now suffer from neurological problems.

One month before 39-year-old Tiffany Barton got remarried, she decided to plump up her lips. There was a "doctor," Mario Nieves Perez, who made frequent visits to the hair salon where she worked as a stylist—the BellaSera Salon in Fresno, CA—offering bargain injections of Restylane for $100. (The national average is $500, according to the American Society for Aesthetic Plastic Surgery.) "I saw the women with Gucci purses coming in to visit him, and it gave me a certain amount of confidence," Barton says. After Perez showed her and her fiancé pictures on a website of what he claimed was his work, she went ahead with the procedure. A month later, on the day of her Las Vegas wedding, she woke up with raised red welts on her throbbing lips (which, thankfully, weren't yet detectable in the photos). When she called Perez, he told her that he had actually injected her with a permanent collagen-based substance called Artecoll, instead of Restylane. "That's when I started getting scared," says Barton. With each passing day, her lips got more swollen and painful; there was no camouflaging the damage a week later. After being turned away by four doctors, she finally found a board-certified dermatologist—Dr. Harry Glassman in Beverly Hills—who would perform three separate surgeries on her lips to remove the unknown chemical (most likely industrial-grade silicone, not Artecoll). "My doctor said it was like chipping into cement—little pieces chunking off," says Barton, who has paid $45,000 out of pocket, the proceeds from a previous divorce settlement, to have a third of her upper lip removed. Her lips, while much thinner and still extremely painful, are finally looking close to normal. Not until she went to the police—four other victims have come forward as well—did she learn that Perez was not actually a doctor. He has since fled to Mexico, and there's a warrant out for his arrest.

The recession has created such a boom in fraudulent doctors that the Florida Department of Health has made more arrests in the first three months of this year than in all of 2003. "I have five investigators," says Bradford Jones, the investigations manager for the Florida DOH's Unlicensed Activities Office, the only office of its kind in the country. "We could double our size, we have so much work."

Sitting next to Jones at a conference table in the concrete bunker of the Intergovernmental Bureau in Miami Gardens, FL, Randy Caballero, a sergeant with the Miami-Dade Police Department's Medical Crimes Unit, says that he has a crushing workload of open cases investigating fake physicians. "A really troubling trend" they have seen lately is licensed doctors knowingly hiring unlicensed doctors. One brought on an unlicensed gynecologist from Cuba, paying her $500 to do vaginal reconstructive surgery on unsuspecting women for which he pocketed $5000 per procedure. "And that's unfortunate, because you, as a customer, think you're doing everything right," says Caballero. "These places are all over TV infomercials, and you think this has got to be legit. Why would they want to jeopardize the business by putting fake doctors in there? But they put them in there. How do you stop a real doctor who is just a bad guy who wants to make money? This isn't something that's going away anytime soon."

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It's easy for charlatans to market themselves as the real deal. Attorney Aronfeld had a case in which a sham plastic surgeon put up a spiffy website and papered his office walls with bogus diplomas—even fooling the Spanish version of Good Morning America on the Telemundo network into featuring him. Aronfeld's client Victoria Arnaiz went in for liposuction and came out with crater-like indentations on her back and cottage-cheese-like lumps rippling across her abdomen. "It turned out the guy wasn't a doctor at all," says Aronfeld. "With Photoshop and a website, I could turn you into a plastic surgeon overnight. They've tweaked the game up so that it's no longer just back-alley kind of stuff. They rent an office—it looks legitimate with the marble floors; it smells nice, and they're wearing doctors' jackets."

Thirty-year-old Andrea Lee understood that her injector was not a doctor. "I'm still in a lot of pain," she says, knowing that she's lucky to be alive. In January, after an acquaintance used a 10-gauge needle to inject her 40 times in the buttocks with silicone (purchased over the Internet from a source in Atlanta), she was rushed by ambulance to Tampa's Town & Country Hospital, unable to walk—her liver, lungs, and kidneys shutting down, clogged with the gelatinous substance. "They didn't expect me to make it," she says today. "They told my mother to start making funeral arrangements." She spent seven days in the ICU and three weeks on dialysis after her kidneys failed; her heart, even after a month in the hospital, is still enlarged. Lee says that she just wanted to have a fuller, rounded rear, like Jennifer Lopez, and that among her friends, illegal hookups of silicone injections given by nondoctors are all the rage. Indeed, just this March, Donnie Hendrix was arrested in Flagler County, FL, for allegedly injecting people with syringes filled with industrial-grade silicone—the kind used for caulking bathtubs. (At press time, he had pleaded not guilty.) And it wasn't the first time: He had served five years in jail for killing a 53-year-old Miami woman who collapsed after he helped inject her with a half-gallon of silicone at a "pumping party" in 2001. "We have heard there's a whole underground network that administers the shots," says Major Harold Winsett of Florida's Hillsborough Country Sheriff's Office. Why do women subject themselves to such shady treatment? Because the contraband substance, used to augment breasts and butts and erase wrinkles, is cheap: Lee paid $500 for her bootleg procedure—as opposed to the $5800 that a legit plastic surgeon on the East Coast would charge for a gluteal augmentation.

Bargain prices are what drew at least three clients per week to 37-year-old Juan David Acosta, who was arrested in April for allegedly performing gluteal augmentation implant surgeries from his lakeside home in Miami. (He has pleaded not guilty.) At $800 a pop, he charged a tenth of what a legitimate doctor would. According to the Miami New Times, detectives found bloody gauze, used syringes, medical chemicals, and unidentified biomaterial (to create the fake buttocks) in his garbage. Sergeant Caballero, who cannot comment on the case as it's still pending, says that he spends most of his days trying to track down people like Acosta, as well as the increasing number of fly-by-night foreign practitioners who prey on women looking for cheaper procedures. "Those transient doctors are hard to catch," he says. "He flies in, is here for a week, and then flies back. We see it a lot." They set up shop in a hotel room, the back room of a beauty salon, or medi-spa—even, says Caballero, in a van.

Luiz Carlo Ribeiro used the basement of a condominium in Framingham, MA. For two years, Ribeiro, who was not a licensed doctor, and his wife blew into this large town next to the turnpike from Brazil on 30-day work visas to perform cheap nose jobs, breast enhancements, and fat suctions on a massage table. Word spread throughout the local Brazilian community: Call Celia, make an appointment, bring cash. And the women, who could not have afforded it otherwise, did.

Then one Sunday afternoon, Fabrioloa DePaula, just 24 years old, handed over $3000 for a liposuction procedure and reclined on his table. Ribeiro injected her with lidocaine, a topical anesthetic, and Rohypnol—otherwise known as roofies, the date-rape drug—and carved several incisions into her belly. Ten minutes later, she stopped breathing. With no medical equipment on hand to help her, Ribeiro and his wife threw DePaula in a car and took her to the emergency room at Metro West Medical Center, where she was pronounced dead. The cause? A pulmonary fat emboli—her own fat clogging her lungs—a complication that could have been easily caught by an anesthesiologist, had one been present.

Although Ribeiro and his wife went to jail in March 2008 and "Celia" has been deported, the assistant district attorney on the case, Lee Hettinger, says that in the course of his investigation, he heard of numerous other illegal, underground cosmetic-surgery operations going on in the area. "This was not an anomaly," he says. "There are a lot of them, working out of beauty shops and other places." To his knowledge, no one is investigating them.

Shirleen Sifford wanted to have a baby. When her doctor recommended that she lose weight before getting pregnant, she decided to get lipodissolve, a nonsurgical—and much cheaper—alternative to traditional liposuction in which a non-FDA-approved chemical cocktail is injected, "melting away" the fat. Information she cherry-picked from the Internet made it seem quick and easy, but what Sifford didn't understand was that the procedure was experimental: There is no standard ingredient list for the synthetic soup (some mixture of soybean extract, hormones, a cattle bile derivative, antibiotics), and where the fat goes (the lymphatic system? The bloodstream?) is anyone's guess.

Sifford found a local medi-spa called AltMed of the Triad in Greensboro, NC, to perform the procedure. She had no reason to doubt its legitimacy: The website looked top-notch and had a doctor's name attached to it, and Lauretta Cheek, the owner, seemed not only professional, but like a friend. "I didn't check her credentials, I didn't investigate her. I just researched the procedure itself," says Sifford today. "I saw her certificates on the wall, and her business card had some initials following her name. It seemed like a safe environment." The day after her third session in which Cheek used dull needles for the 100 injections of a double dose of chemicals—Sifford couldn't stop crying. Unable to walk or catch her breath, she was rushed to the emergency room. She had a near-fatal blood infection.

This February, Sifford was awarded a $500,000 settlement—by default: Cheek never showed up in court. At the time, she was already facing 20 felony counts for prescription fraud, and a charge for practicing medicine without a license. Cheek—a nurse's assistant—wasn't just performing lipodissolve. In December 2008, she injected three women with what she claimed was SilSkin, a silicone oil not FDA-approved for cosmetic use, to enhance their buttocks. Within 24 hours, all three were in the hospital, two on dialysis with acute kidney failure. To this day, no one knows what she injected into their bodies.

"Nurses and beauticians and electrologists are doing these procedures now," says Dr. Mathew Avram, the director of the Massachusetts General Hospital Laser and Cosmetic Center in Boston. "It's a huge problem that is going to worsen." Many of these non-docs, like Cheek, find legal employ in medi-spas, the fastest-growing segment of the $11 billion spa industry, which doubled its revenues between 2006 and 2007 and hauled in $1 billion in profits last year. Though these hybrid retail operations have caused injuries and deaths, they lack any national standards and oversight organizations.

Most state boards dictate that anything affecting the structure or function of the skin qualifies as a medical procedure, and must be performed or supervised by a doctor. But states vary vastly on what "supervision" means. New Jersey, for instance, mandates that only medical doctors can operate laser devices (enforcement is another issue), while Massachusetts does not have any laws stipulating supervision of laser devices. That's where ghost medical directors come in. Dermatologist Dr. Jeffrey Dover, the director of SkinCare Physicians in Chestnut Hill, MA, has received letters from strangers asking him to lend his name to a medi-spa. "They say, 'We'll pay you a monthly retainer, and you don't ever have to come here,'" he says. Dover has refused three such offers, but knows of colleagues who have essentially rented out their licenses for extra annual income estimated to be in the $80,000 range.

Sacramento, CA, lawyer Charles Barrett has a client who received second-degree burns inside her vagina—the resulting scars may prevent her from having kids—from Brazilian-style bikini-line laser hair removal done at a franchise laser-spa by a nurse. The spa's medical director, an EMT, says Barrett, was affiliated with more than 70 medi-spas nationwide. "He was never on the premises and basically just rented out his license," Barrett says. "He never even provided training."

In a 2008 survey by the American Academy of Facial and Plastic Reconstructive Surgery, more than 75 percent of its doctors said that they were aware of a medi-spa with a medical director who was not on-site performing, or even overseeing, medical procedures. Detective Craig Cotten, of the Guilford County Sheriff's office, says that Cheek used the name of a local family doctor to write prescriptions. At one point, she paid that doctor to be at her medi-spa a few hours a week and in return, posted the doctor's name on her website and in her office, luring in women like Sifford, whose waist is now covered with knotty, painful keloids and whose dream of starting a family is on hold.

"We are seeing more patients trying to save money at a medi-spa who then have to come to us anyway," says Dr. Robert Weiss, president of the American Society for Dermatologic Surgery, pointing out that the cost of fixing a botched procedure—which insurance will not cover—far exceeds paying a legitimate doctor's fee. "You have businessmen running them, hiring people to administer treatments who would normally be checking out your groceries. It's our philosophy that only M.D.s should be doing the injections and lasers. Botox, the most toxic chemical ounce for ounce, should only be in qualified hands," Weiss says.

It was while Massachusetts Senator Joan Menard was getting her own Botox and dermal filler fix from Dover that she first learned of the exponentially increasing incidents of women cramming his waiting room after having been burned and disfigured at medi-spas. "There were no regulations," Menard says. "None." So she formed the Massachusetts Medical Spa Task Force to look into the problem. It found that there was no way to discern what sort of training—if any—non-medical practitioners had. Menard's goal is to ensure a trained and licensed professional does every procedure. After the task force met for three years, Menard sponsored Senate Bill 836, based on its recommendations to set up a broad statutory licensing scheme and requirements for medi-spas that she'd hoped would eventually serve as a model for the rest of the country. But at the hearing before the Public Health Committee in July, she was met with stiff opposition—from businesspeople and, in particular, cosmetologists—who feared the negative financial impact it could have on their lucrative industry. Now Menard is busy retooling a draft that will, perhaps, make everyone happy—but also may not protect consumers as well. Indeed, Dover, who served on the task force, testified at the hearing that the bill in its current form is too lenient, allowing nurses and aestheticians to perform unsupervised procedures. "There are still a lot of concerns; it's a lot of learning," Menard says, vowing to continue a fight that could last several more years.

Rigorous legislation can't come soon enough. Also last July, Debra O'Gara-Schultz, a nurse and owner of Superior Laser Aesthetics in Superior, CO, was arrested for allegedly forging a doctor's name to purchase and inject Botox and Restylane. (At press time, she had not yet entered a plea.) And Dover just examined a patient who revealed she was having Botox done in her home by a nurse who was charging one-fifth of his fee.

Meanwhile, women like Deyanira Polledo and Lissette Pita will continue to pay a steep price. How many more will be injured or killed when unbound vanity collides with unscrupulous practitioners who will do just about anything to make a buck?

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WHAT'S IN A NAME?

Before signing up for surgery, consider your doctor's credentials: Unlike "aesthetic plastic surgeons"—plastic and reconstructive surgeons who specialize in cosmetic procedures and undergo at least seven years of training—"cosmetic surgeons" aren't subject to any regulation in the U.S. That means that anyone with a medical license (but not necessarily any surgical experience) can use the title. To check your surgeon's credentials, consult with the American Board of Medical Specialties (abms.org).

DON'T BE A VICTIM, Spencer Aronfeld, Esq.

1. Check your state's licensing board for your doctor's name and confirm his policy with the insurance company. Board-certified doctors have at least a year of hands-on experience and have met vigorous industry standards.

2. Check if the doctor has staff privileges at the local hospital.

3. Verify that the before/after pictures are authentic and ask previous patients about their pre- and post-op experiences.

4. Avoid practitioner-anesthesiologists—twice the work means divided attention.

DON'T INJECT YOURSELF

Sounds like a no-brainer, but sites like discountmedspa.com shamelessly serve up knockoff Botox and Restylane to any desperate housewife, and even offer videos on how to self-inject. But if you don't want nerve damage or disfigurement with your inflated lips (as corrective plastic surgeons like Dr. Andrew Jacono of Manhasset, NY, have seen), then steer clear. The bottom line: "The concept of performing injections on yourself is similar to performing surgery on yourself," says Dublin, CA, plastic surgeon Dr. Steven Williams.

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