Lenia Watson-Burton, a 37-year-old U.S. Navy administrator, expected that cosmetic surgery would get rid of stubborn fat quickly and easily — just as the web advertising promised.

Instead, she died three days after a liposuction-like procedure called AirSculpt at the San Diego office of Elite Body Sculpture, a cosmetic surgery chain with more than 30 offices across the U.S. and Canada, court records show.

Cosmetic surgery chains setting up shop in multiple states depend heavily on advertising to attract customers: television, print, social media influencers, even texts hawking discounted holiday rates. The pitches typically promise patients life-changing body shaping with minimal pain and a quick recovery.

Yet there’s no federal requirement that surgery companies post evidence supporting the truth and accuracy of these marketing claims. No agency tracks how frequently patients persuaded by sales pitches sustain painful complications such as infections; how effectively surgeons and nursing staff follow up and treat injuries; or whether companies selling new aesthetic devices and methods have adequately trained surgeons to use them safely.

In 2023, Watson-Burton’s husband and six children and stepchildren sued Elite Body Sculpture and plastic surgeon Heidi Regenass for medical malpractice, alleging that the thin cannula the surgeon used to remove fat perforated Watson-Burton’s bowel, causing her death.

The suit also accused Elite Body Sculpture of posting false or misleading advertising on its website, such as describing the clinic’s branded procedure AirSculpt as “gentle on the body” and stating: “Our patients take the fewest possible risks and get back to their regular routine as soon as 24-48 hours post-operation.”

Watson-Burton was one of three patients who died after having liposuction and fat transfer operations performed by Regenass from October 2022 to February 2023, court records state. Families of all three women sued the surgeon, who denied wrongdoing in legal filings. The parties settled the Watson-Burton family case in 2024. Two other wrongful death cases are pending, including a suit by an Ohio woman who alleges her mother relied on promises on Regenass’ website that the operation in California would be safe with a quick recovery.

Neither Regenass nor her attorneys responded to repeated requests for comment. Emails and phone calls to Elite Body Sculpture’s Miami headquarters were not returned.

State and federal authorities do have the power to prohibit false or misleading medical advertising of all types, though enforcement is spotty, particularly when promotions pop up online. That means patients must do their own homework in evaluating cosmetic surgery marketing pitches.

“While consumers should be able to trust that ad claims are substantiated because the law requires them to be, the reality is that it pays for consumers to bring a skeptical eye,” said Mary Engle, an executive vice president at BBB National Programs.

‘Up a cup’

Founded by cosmetic surgeon Aaron Rollins, Elite Body Sculpture says in Securities and Exchange Commission filings that it offers a “premium patient experience and luxurious, spa-like atmosphere” at its growing network of centers. The publicly traded company, based in Miami Beach and backed by private equity investors, markets AirSculpt as being “much less invasive than traditional liposuction” and providing “faster healing with superior results.” The ads say that AirSculpt “requires no scalpel, or stitches, and only leaves behind a freckle-sized scar!” and that patients “remain awake the whole time and can walk right out of their procedure, enjoying dramatic results!” Some risks are disclosed.

Rollins, who recently made headlines for putting his Indian Creek mansion on the market for $200 million, did not respond to repeated requests for comment. A lawyer for Rollins, Robert Peal, responded to an email but didn’t comment. On Nov. 4, the company announced that Rollins had resigned as executive chairman of the board of directors of AirSculpt Technologies Inc. and as a member of the board.

Many AirSculpt patients opt to have fat that is removed from their stomachs or other places injected into their buttocks, often called a Brazilian butt lift. Others use the fat to enhance their breasts, a procedure the company brands as “Up a Cup.” Since March 2023, at least seven patients have filed lawsuits accusing Elite Body Sculpture of running misleading advertising or misrepresenting results, arguing, among other things, that they felt more pain or healed much more slowly than the ads led them to believe they would, court records show. One of the lawsuits has been dismissed, and the company has denied the allegations in others.

The Watson-Burton family argued in their lawsuit that some marketing claims about AirSculpt were simply not true.

For instance, Elite Body Sculpture’s website stated that AirSculpt has “automated technology” set to “turn off” before the cannula penetrates the body too deeply and possibly causes serious injury, according to the suit. That feature didn’t protect Watson-Burton, who paid $12,000 for the operation, hoping for a “quick and timely recovery” before a scheduled U.S. Navy deployment, according to the lawsuit.

Rather than being gentle on the body, AirSculpt was “extremely painful, highly invasive, unsafe, required more than a short 24-hour recovery period and could and did damage internal organs,” according to the suit.

Watson-Burton called the San Diego center on Oct. 27, 2022, a day after the operation, to report “severe pain” in her upper abdomen, but staffers took no action to evaluate her, according to the suit. The next morning, an ambulance rushed her to a hospital, where emergency surgery confirmed the gravity of her injuries. Surgeons noted her injuries included three perforations of the small bowel and sepsis.

Watson-Burton died on Oct. 29, 2022. An autopsy report cited complications of the cosmetic surgery, ruling she died after becoming “septic following intraoperative small bowel perforation.” Her death certificate lists the cause as “complications of abdominoplasty.”

In court filings, Elite Body Sculpture said Watson-Burton had “experienced an uncommon surgical complication.” The company denied that it made any “specific guarantee or representation that injury to organs could not occur.” It denied any liability or that its ads made misrepresentations.

The dispute never played out fully in court. The parties settled the case in August 2024, when Elite Body Sculpture agreed to pay Watson-Burton’s family $2 million, the maximum under its insurance policy. Regenass, the surgeon, who did not carry liability insurance, agreed to pay $100,000 more, according to the settlement agreement.

Promises not kept

Social media pitches and web advertising also led Tamala Smith, 55, of Toledo, Ohio, to Regenass for liposuction and a fat transfer, court records state.

Smith was dead less than two weeks later, one of two other women who died following elective operations Regenass performed from December 2022 to February 2023, court records show. The surgeon operated on the two women at Pacific Liposculpture, which runs three surgery centers in Southern California, court records state.

The families of both women are suing Regenass, a board-certified plastic surgeon, and the surgery center. In both cases, which are pending in California courts, Regenass and the surgery center have denied the allegations and filed dismissal motions that deny responsibility for the deaths.

Smith was a traveling registered nurse working the overnight shift at a hospital in Los Angeles. She chose Regenass after viewing the doctor’s Instagram page, according to a lawsuit filed by Smith’s daughter, Ste’Aira Ballard, who lives in Toledo.

The ads described the surgeon as an “awake liposuction and fat transfer specialist,” while her website assured patients they would feel minimal pain and be “back to work in 24-48 hours,” according to the suit.

During the three-hour operation on Feb. 8, 2023, at Pacific Liposculpture’s Newport Beach office, Regenass removed fat from Smith’s abdomen and flanks and redistributed it to her buttocks, according to the suit. Smith called the office at least twice in subsequent days to report pain and swelling, but a staffer told her that was normal, according to the suit. Smith never spoke to the surgeon, according to the suit.

When Ballard couldn’t reach her mother, she called the hospital only to learn Smith hadn’t turned up for her overnight shift for two days. The hospital called police and asked for a welfare check at the extended-stay hotel in Glendale, California, where Smith had been living.

An officer discovered her body on the bed “surrounded by towels and sheets that are stained with brown and green fluids,” according to a coroner’s report in the court file. A countertop in the room was “covered in medical paperwork detailing post-operative instructions from a liposuction clinic,” according to the report. Ballard said she learned of her mother’s death when she called Smith’s cellphone; a police officer answered and delivered the devastating news.

“Oh, my God, I fell to the floor,” Ballard said in an interview with KFF Health News and NBC News. Ballard said she still has not gotten over the shock and grief. “It bothers me because how does someone that dedicated their life to save other people’s lives end up deceased in a hotel, as if her life didn’t matter?” she asked.

Ballard said her mother trusted Regenass based on her web persona. She believes her mother, a registered nurse, would not have gone to the surgeon had she known someone had died after an operation Regenass performed at the Pacific Liposculpture San Diego office. Terri Bishop, 55, a truck driving instructor who lived in Temecula, California, died on Dec. 24, 2022, about three weeks after undergoing liposuction and fat transfer at Pacific Liposculpture, a company with a history of run-ins with state regulators.

Pacific Liposculpture did not respond to requests for comment. In court filings, the company has denied that the operations played a role in either patient’s death and moved to dismiss the cases. The company also argued that Ballard waited too long to file suit.

Bishop, who had a history of smoking, diabetes and high blood pressure, died from “arteriosclerotic cardiovascular disease aggravated by viral pneumonia (Influenza A H1 2009),” according to a Riverside County medical examiner’s report made part of the court record. The family disagrees and is arguing that Bishop died from blood clots, a known complication of surgery. A trial is set for June 2026.

In Smith’s case, the Los Angeles County medical examiner ruled the nurse died of “renal failure of unknown cause.” The autopsy report noted: “This is a natural death since an injury directly from the surgery cannot be identified.”

Ballard is demanding further investigation to get to the bottom of what happened to her mother.

“I don’t think they were straightforward with the risk and complications that could occur,” Ballard said. “I think they are promising people stuff they can’t deliver.”

Ballard filed a complaint against surgeon Regenass with the California Medical Board, which the board is investigating, according to documents she provided to KFF Health News and NBC News. She believes regulators need to be more transparent about the backgrounds of surgeons who offer services to the public. She also hopes the investigation will shake loose more details of what happened to her mother.

“I just don’t understand how she came back to me in a body bag,” she said.

What the law permits

Concerns about sales pitches for cosmetic surgery date back decades.

Witnesses testifying at a June 1989 congressional hearing held by a subcommittee of the House Small Business Committee in Washington heard a litany of horror stories of patients maimed by surgeons with dubious training and credentials. Subcommittee Chairman Ron Wyden, D-Ore., said patients were victimized by deceptive and false ads that promised a “quick, easy and painless way to change your life — all through the cosmetic surgery miracle.”

Calling for reform, Wyden added: “So, cosmetic surgery consumers are largely on their own. It’s back to a buyer beware market, and it smacks more of used car sales than medicine.” Wyden now represents Oregon in the U.S. Senate.

All these years later, there’s far more territory to police: an onslaught of web advertising, such as splashy “before and after” photos, online posts, and podcasts by social media influencers and others courted by surgery companies in a costly effort to attract business. Elite Body Sculpture, for instance, spent $43.9 million in “selling expenses” in 2024. That came to $3,130 per “customer acquisition,” according to the company’s SEC filings.

Under Federal Trade Commission guidelines, medical advertising must be “truthful, not deceptive, and backed up by competent and reliable scientific evidence,” according to Janice Kopec of the agency’s Bureau of Consumer Protection.

Any claims that are “suggested or reasonably implied” by ads also must be accurate. That includes the “net impression” conveyed by text and any charts, graphs and other images, according to the FTC. The agency declined to elaborate.

Medical businesses are free to decide what documentation, if any, to share with the public. Most cosmetic surgery sites offer little or no such support for specific claims — such as recovery times or pain levels — on their websites.

“There is no requirement that the substantiation be made available to consumers, either on a website or upon demand,” Engle, who is also a former FTC official, said in an email.

The law permits “puffery,” or boastful statements that no person would likely take at face value, or that can’t be proved, such as, “‘You’ve tried all the rest, now try the best,’” Engle said.

Where to draw the line between acceptable boasts and unverified claims can be contentious.

Athēnix, a private equity-backed cosmetic surgery chain with locations in six cities, defended its use of terms such as “safer” and “better results” as puffery in response to a false advertising lawsuit filed against the company by Orange County District Attorney Todd Spitzer in California in August 2022.

Spitzer argued that Athēnix touted its “micro-body-contouring” technique as “safer” than traditional liposuction and offered “outstanding results with less pain and downtime” without backing that up, according to the suit.

“There is no study or evidence to support these statements and no scientific consensus about the use of these new techniques,” Spitzer argued.

The parties settled the case in July 2023, when Athēnix agreed to pay $25,000 without admitting wrongdoing, court records show. Before the settlement, Athēnix argued that its use of terms such as “safer” and “better results” was “subjective” and “puffery” — and not false advertising.

While there’s little indication that local or state authorities are stepping up scrutiny of cosmetic surgery advertising, federal authorities have signaled they intend to crack down on dubious advertising claims made by drug manufacturers.

In a letter sent to drug companies in September, FDA Commissioner Marty Makary wrote that “deceptive advertising is sadly the current norm” on social media platforms and that the agency would no longer tolerate these violations.

‘Bad advice’

To prove medical negligence, injured patients generally must show that their care fell below what a “reasonably prudent” doctor with similar training would have provided. In their defense, surgeons may argue that complications are a risk of any operation and that a poor outcome doesn’t mean the doctor was negligent.

Some lawsuits filed by injured patients add allegations that advertisements by surgery chains misled them, or that surgeons failed to fully explain possible risks of injuries, a requirement known in medical circles as informed consent.

Caitlin Meehan had such a case. She underwent a $15,000 AirSculpt procedure at Elite Body Sculpture’s clinic in Wayne, Pennsylvania, outside Philadelphia. She agreed to the surgery in March 2023, she said, because the company’s website described it as “Lunch Time Lipo,” according to a lawsuit she filed in late August. The suit alleges that the doctor she discussed the procedure with “maintained that there are no serious, life-threatening, lasting and/or permanent complications,” according to the suit.

During the procedure, however, gases became trapped beneath her skin, causing a widespread swelling called subcutaneous emphysema, according to the suit. Meehan was shocked to see her face, neck, and upper body severely swollen, causing her shortness of breath.

A friend who drove her to the appointment asked the staff to call an ambulance, but staff members said that wasn’t necessary, according to the suit. After an hour’s drive home, Meehan said her skin felt like it was burning and she called 911. She spent four days in the hospital recovering and remains scarred, according to the suit. The suit is pending, and the company has yet to file an answer in court.

Scott Hollenbeck, immediate past president of the American Society of Plastic Surgeons, said recovering from liposuction in a day “seems unrealistic” given the bruising and swelling that can occur.

“The idea that you could return to work 24 hours after effective liposuction seems like extremely bad advice,” Hollenbeck said.

Ads that promised patients minimal discomfort also have come under attack in patient lawsuits.

More than 20 other medical malpractice cases reviewed by KFF Health News made similar allegations of unexpected pain during operations at cosmetic surgery chains using lidocaine for pain relief in “awake liposuction.”

One patient suing Elite Body Sculpture in Cook County, Illinois, alleged she “was crying due to [the] severe pain” of an operation in September 2023. She alleged the doctor said he couldn’t give her any more local anesthetic and pressed on with the procedure. The defendants have not filed an answer in court. The practice didn’t respond to a request for comment.

Engle, the former FTC official, said that while claims of discomfort are somewhat subjective, they still must be “truthful and substantiated,” such as supported by a “valid, reliable clinical study of patients’ experience.”