Colleen Fledderman was getting anxious as she sat in the doctor's waiting room.
Her daughter Amy, 18, had gone in for liposuction surgery shortly after 9:30 a.m. It was past noon, and she still wasn't out.
Fledderman thought back to the appointment a week earlier when her daughter signed up for the surgery that would suction fat from her chin and stomach.
The plastic surgeon had been reassuring about the popular procedure, Fledderman recalled.
"This is liposuction," Fledderman, of Newtown Square, Delaware County, said the doctor told her when she inquired whether anything bad could happen. "She is zero risk. She's a textbook case. She's young, healthy. She's the kind of patient everyone would want to operate on."
But by the time Fledderman's wait finally ended on May 23, her active, athletic daughter was being rushed off by ambulance, struggling to breathe.
Forty-eight hours later, Amy Fledderman was dead from a complication of liposuction surgery.
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Liposuction is now the most common cosmetic surgical procedure in the country. It is estimated that anywhere from 377,000 to 673,000 procedures were done last year - far outpacing face-lifts and nose jobs. A precise number is hard to know because many types of doctors perform liposuction.
Because liposuction is rarely covered by insurance, patients must pay - on average about $4,000, according to the American Academy of Cosmetic Surgery.
The procedure entails a tube inserted under the skin; fat is then broken up and vacuumed out. Though safe for most patients - who end up delighted with their thinner thighs and flatter bellies - serious complications, even death in rare instances, can occur.
As with any operation, there are risks associated with anesthesia, infection, bleeding and blood clots. But there is also the rare and potentially fatal complication of fat clots. During the suctioning process, fat globules can escape, get into the bloodstream and travel to the lungs, leading to respiratory distress.
"Liposuction is not trivial surgery," said Dr. Rudolph H. de Jong, a former professor at Thomas Jefferson University who, for a study, counted 95 deaths nationwide from liposuction between 1994 and '98.
"It should not be taken too lightly."
The story of Amy Fledderman's death is based on interviews with her family, friends and patient records citing Richard P. Glunk, a King of Prussia doctor, as her surgeon. The family initially was reluctant to talk about their daughter, and only recently agreed to do so.
Glunk, referring to doctor-patient confidentiality rules, said that discussing any patient would be unethical. "I can't even discuss whether she is or is not a patient," he said in an interview.
Glunk, 44, said he has been in practice 14 years, carefully selects his patients, and runs an office equipped to handle emergency situations.
He said he is certified by the American Board of Plastic Surgery, a member of the American Society for Aesthetic Plastic Surgery, and has admitting and operating privileges at Lankenau, Bryn Mawr and Paoli Memorial Hospitals.
Amy Fledderman was home from Pennsylvania State University for Christmas break when she told her parents she wanted to have the liposuction procedure.
At 5-foot-5 and 128 pounds, she wasn't overweight. She had lost 25 to 30 pounds over several years, chipping away at her weight through sound eating and exercise.
At Penn State, she ran at least three miles most days, impressing her friends with her speed. In a poem for her freshman English class, she wrote whimsically about her workouts with her roommate and their determination to stave off the legendary weight gain of new college students: "They run together every day; So back off, freshman 15."
Still, she couldn't shed a small stomach bulge and one under her chin.
Colleen Fledderman, a reading specialist, checked out some plastic-surgery sites on the Internet and watched a TV show about liposuction. She found nothing alarming, and her daughter's request didn't seem extreme to her and her husband.
After consulting with family doctors, Amy had had surgery when she was 16 to correct a developmental abnormality involving her breasts. Glunk had been the surgeon and the operation had gone well.
Amy Fledderman, the middle child of three, was a sensible girl who worked hard at everything she did. She was an honors student at Marple Newtown High School. She co-captained the tennis team, and her French-horn skills earned her a spot on the Pennsylvania Music Educators Association All-State Orchestra.
At Penn State, she was pursuing a major in bioengineering, with an eye toward genetics. She had taken on a heavy load of science and math courses, earning about a 3.3 average. She also made the equestrian team.
"When we do tryouts, one of the things we look for is smiling faces. And she certainly was one of them," equestrian coach Malinda Grice said.
Amy Fledderman followed the family tradition in choosing Penn State and enjoyed spending time with her brother, Joseph, a senior. Renee, now 13, the Fledderman's younger daughter, idolized her sister.
The Fleddermans were the ever-present parents, attending concerts and chaperoning school trips. Daniel Fledderman, who has an engineering consulting business, sometimes drove four hours to Penn State just to lunch with his daughter.
Amy's closest friends at home and college said later that they had no idea she wanted the operation. They said she was cheerful, fun-loving, adventurous, and down to earth, not fixated on appearance.
Kristen Shehab, a college friend who earned her karate yellow belt with Amy, said: "It completely baffled my mind . . . because she was always the kind of person who was very secure with herself."
The number of serious complications and deaths caused by liposuction is not known, in large part because it is performed outside the review of insurance companies and many states do not require doctors to report cases that go awry. There also have been few studies.
The 95 liposuction-related deaths between 1994 and 1998 came to light in a survey of 1,200 members of the American Society for Aesthetic Plastic Surgery. De Jong, who did the survey, used the 95 deaths to calculate that the mortality rate was about 20 for every 100,000 procedures. By comparison, the death rate for hernia repair was 3 per 100,000.
A leading cause of liposuction death, de Jong found, was pulmonary embolism - a clot made of blood, or in rarer instances fat, that can damage the lungs.
Other fatal complications of liposuction included perforations of the abdominal wall, anesthesia problems and cardiorespiratory failure, de Jong and a co-author wrote last year in the journal Plastic and Reconstructive Surgery.
More common problems are skin irritation, pain and swelling.
A survey published in May found that when liposuction is done alone, not in combination with another surgical procedure, the death rate is about 2 in 100,000, but higher otherwise.
The author, Charles Hughes 3d, an Indianapolis plastic surgeon, reported that doctors are now more apt to limit the duration of the surgery, remove smaller volumes of fat, and avoid liposuction in combination with other procedures.
On May 15, home for summer break, Amy Fledderman went with her mother to see Glunk at his office near the King of Prussia mall.
Amy Fledderman explained to Glunk that some pockets of fat wouldn't go away, Colleen Fledderman recalled. She asked whether there was anything she could do to lose them.
"Absolutely not. It's genetic fat, and the only way to lose it is liposuction," she said Glunk told Amy.
Fledderman said Glunk explained that he wouldn't have to take much fat out. The procedure would involve five tiny incisions in the abdominal area and one under the chin. He would use an ultrasound device to help break up the fat and a tiny tube to suction it out. She would be asleep.
On the liposuction consent form Amy signed, Glunk listed risks: "infection, bleeding, scarring, pain, numbness, loss of skin, injury to surrounding structure, facial-nerve numbness, facial-nerve weakness, residual deformity, facial-nerve paralysis." There was also an anesthesia consent form.
The worst thing that could happen, Colleen Fledderman recalled Glunk saying, was that Amy could end up with a drooling problem because of the liposuction below her chin, but that that could be fixed with a stitch.
Fledderman said she asked about the dangers of a blood clot, and whether the procedure was safe to do in his office. She said Glunk indicated everything would go smoothly.
Glunk told the Fleddermans that he normally charged $6,500 for the surgery, but because Amy was a previous patient, he would charge $5,000, Fledderman said.
When Colleen Fledderman discussed the matter with her husband, she said, "I said to Dan, he's making it sound like wisdom teeth."
A few days before surgery, Amy confided in her 18-year-old cousin, Erica Yanoshak, who asked why she wanted it and whether it was dangerous.
"She said, 'If there's nothing that can happen to me, I might as well,' " Erica recalled.
More than half of all cosmetic surgery is done in doctors' offices, part of a national trend to move many types of surgery out of hospitals.
Performed in a well-equipped, well-staffed office with careful selection of patients, liposuction is usually safe, experts say. But because there is much less oversight of doctors' offices than hospitals, the built-in safeguards can vary.
"There is a formal, systematic process in hospitals looking at the qualification and competency of the physicians. . . . This level of oversight is typically not required in office-based surgery practice," said Dr. Robert Wise, vice president for standards at the Joint Commission on Accreditation for Healthcare Organizations.
But there is a growing push among professional groups and state regulators for accountability.
By next summer, the American Society for Aesthetic Plastic Surgery will require members who operate outside hospitals to perform surgery only in accredited surgical facilities if they use anesthesia.
In Florida, rules now require doctors' offices to meet anesthesia standards, report deaths and complications, and follow guidelines that steer high-risk patients to hospitals for surgery. As for liposuction, Florida limits the amount of fat that can be removed in certain cases.
New Jersey adopted rules several years ago for office surgery, requiring doctors to report deaths and serious complications, and to post a written emergency back-up plan.
In Pennsylvania, the state Health Department issued rules in 1999 to bring some oversight to the growing business of office-based surgery. The rules require doctors' offices that have a section set aside for surgery to be registered or licensed as an "ambulatory surgical facility," meeting the same standards required of larger non-hospital surgical centers.
After Amy Fledderman and her mother arrived at Glunk's office on May 23, Amy changed into a hospital gown and Glunk marked the target spots on her body.
"I said to him, 'You're going to take good care of her,' " Colleen Fledderman said.
With her daughter in surgery, Fledderman settled in to wait.
Sometime after noon, Fledderman asked the receptionist to check on her daughter, and she reported that the operation was almost over.
Around 1:30 p.m., Glunk came in.
"The surgery is over. Everything went well. We're just having trouble waking her up," Fledderman said Glunk told her. He reassured her, saying that teens sometimes don't want to come out of anesthesia, she said.
He came out again a short time later to ask whether Amy was the anxious type. He said she was having a "rough emergence" from anesthesia, Fledderman said, and seemed to be fighting their efforts.
"He said she's having a panic attack," Fledderman said.
She said she assured the doctor that her daughter was a calm person and asked whether he should call for an ambulance.
Fledderman told Glunk she wanted her daughter in the hospital. She said he answered, "They don't admit patients for rough emergence."
Glunk gave some other updates throughout the afternoon, Fledderman said, and she again asked about taking Amy to the hospital. He indicated there was no need, she said.
Shortly before 4 p.m., Glunk told Fledderman that Amy was waking up, she recalled.
The next thing Colleen Fledderman knew, a staffer was at her side, telling her that Amy had fluid in her chest and they were calling an ambulance.
Glunk's operating note, obtained by the family, said: "Decreased breath sounds and difficulty with oxygen saturation developed and need for admission was discussed with mother." The note did not indicate when he made the observation.
Upper Merion records show that police were dispatched at 4:11 p.m. for a respiratory emergency.
Fledderman rushed to the operating room. Her daughter was on the table, eyes open, looking panicked, she said.
Fledderman said Glunk wanted Amy taken to Paoli Memorial, where he has privileges. But when the ambulance crew arrived, they insisted on nearby Montgomery Hospital in Norristown, she said.
Fledderman said an ambulance attendant told her: "She'll never make it to Paoli. She's in severe respiratory distress."
That night in intensive care, Amy couldn't talk because she was hooked to a breathing tube. But she scribbled on a pad: "I really hurt." "I'm scared." "I'm sorry, Mom."
The next morning, the Fleddermans first heard the term fat embolism, or fat clot.
"I think she has a fat embolism from the liposuction," Fledderman said the doctor in charge of Amy's hospital care, Robert Belasco, told her and other relatives. He indicated that would explain her breathing problems, Fledderman said.
Belasco, who a hospital spokesperson said was the doctor overseeing Amy, did not respond to a request for an interview.
The Fleddermans said they were concerned that morning because Amy didn't look good, but the medical staff seemed optimistic.
As the day wore on, the Fleddermans heard more worry in the updates they got. They slept at the hospital. Colleen Fledderman was awakened about 4:30 a.m. May 25 with the news, "She's coughing up blood and she's asking for you."
In the ICU, staff were "bagging" Amy, an emergency effort in which oxygen is pumped manually into the body. Fledderman took her daughter's hand. Eventually, Amy was put back on the ventilator.
With their daughter deteriorating, the Fleddermans set in motion a plan to have her flown to the Hospital of the University of Pennsylvania. She was transferred that afternoon, two days after the liposuction surgery.
At Penn, the family gathered around. "We all said hello to Amy and her heart rate would go up," Daniel Fledderman said, but she couldn't rally.
At 4:35 p.m., Amy Fledderman was declared dead. A priest gave her the last rites.
Because her death was unexpected, it was reported to the Philadelphia Medical Examiner's Office, which ruled the cause a complication of fat embolism due to liposuction.
The state Health Department said Friday that based on a complaint, it is investigating whether Glunk's office is an ambulatory surgical facility operating without the necessary license. Deputy Health Secretary Richard Lee said the Pennsylvania Department of State, which oversees licensing of doctors, is also involved.
Glunk, in an interview Friday, said he is in compliance with state rules.
The Fleddermans have set up a scholarship in Amy's memory. They're also consulting lawyers about their legal options.
"We never would have let her do it if we knew she could have died," Colleen Fledderman said. "It wasn't supposed to be a big deal."
Susan FitzGerald's e-mail address is sfitzgerald@phillynews.com. Marian Uhlman's is muhlman@phillynews.com.
If You're Thinking About Liposuction
* Liposuction is not a weight-reduction method. It is a surgical procedure used to eliminate pouches of fat.
* Check out the training and credentials of the doctor. Does the doctor have privileges to admit patients and operate at a hospital?
* Ask how often the doctor does the procedure.
* Discuss where the best place is to have surgery - a hospital, surgicenter or doctor's office.
* If the procedure is being done in a doctor's office, find out whether the facility is accredited. Three major groups that review doctors' offices are the Joint Commission on Accreditation of Healthcare Organizations, American Society for Accreditation of Ambulatory Surgery Facilities, and the Accreditation Association for Ambulatory Health Care.
* If the procedure is done in a doctor's office, find out about backup emergency plans.
* Remember that all surgeries carry risks.
