New Yorkers flock to the Dominican Republic for cheaper plastic surgery procedures, but not all of them return home.

Sharilene Cedeño used to joke with her sister Kendra that she was going to be 23 forever.

Cedeño, daughter of Dominican immigrants, was obsessed with staying young – and by extension, plastic surgery. Coworkers at the Manhattan clinic where she was a nurse’s assistant would catch her looking at dramatic before and after photos on surgeons’ social media pages.

One day she saw a friend’s Instagram post after a procedure by surgeon Edgar Contreras, who’s based in the Dominican Republic. That was it. After years of feeling unattractive compared to women who had “gotten done”, Cedeño was ready. Her friend Tiffany Concha, from the Bronx, would join her for her own procedure. “We’re going to become Barbies,” Cedeño told her.

They flew to the Dominican Republic for liposculpture – a procedure during which excess fat removed from the stomach or back is injected into the buttocks.

At 6am on 23 April 2015, the women drove to the Clínica Plástica Contreras (Contreras Plastic clinic), a modern office in Arroyo Hondo, a wealthy neighborhood in the country’s capital, Santo Domingo. Cedeño went into the operating room at noon. Hours later, Concha, lined with purple surgical marker under her medical gown, had not heard anything about Cedeño’s surgery.

At about 4pm Dominican time, Kendra answered a WhatsApp video call at her home in Harlem from Concha, whose face was streaked with tears.

“Are you calling me to say that my sister is dead?” Kendra asked. “You’re not calling me to tell me that.”

But that was exactly what Concha had called to say: Cedeño died of an embolism during her procedure.

She was 23 years old.

Cedeño is one of 12 known cases of New Yorkers who have died from plastic surgery procedures in the Dominican Republic in the last six years. More than 700,000 Dominicans live in New York, creating a natural pipeline between the two places. It runs even more smoothly for those seeking plastic surgery on the Caribbean island, where procedures are far cheaper: the average cost of liposuction in the US is $5,500, compared to $3,500 in the Dominican Republic.

In 2018, more than 23,000 plastic surgeries were performed in the Dominican Republic and more than 18,000 of those were on foreigners. However, like Cedeño, not all who go there to get work done return home.

In June, Manuel Núñez, a New Yorker who had also gone to get liposculpture, died under the knife in a Dominican operating room. According to Telemundo, the doctor who operated on him was actually a gynecologist. He had a past history of negligence and was charged for the deaths of two women in 2015 but the charges were dropped for lack of evidence.

Then in July, Alexandra Medina, a 33-year-old from Yonkers, became the second New Yorker and third American to die within a month in a Dominican plastic surgery clinic when she went for a tummy tuck.

Of the 12 New Yorkers who have died in Dominican plastic surgeries in the last six years, all but one underwent multiple surgeries at once. All 12 were black or Hispanic.

Dr Myla Bennett, an Atlanta-based plastic surgeon who describes herself as a safe surgery advocate, started to speak out against botched plastic surgeries abroad on her social media pages a few years ago after realizing most patients being hurt and killed were women of color or people of lower socioeconomic status.

The Dominican Republic doesn't adhere to the same US regulations on surgeries, which increases the likelihood of heart failure

Bennett said the Dominican Republic doesn’t adhere to the same US regulations concerning how much body fat can be removed in one surgery, which increases the likelihood of heart failure and other consequences during procedures.

Despite the risks that come with surgery, she says people continue to flock to the Dominican Republic, because that’s where they can get an extreme Coke bottle figure for a lower cost.

“The ladies want this particular shape – a really exaggerated form with a small waist and big ole’ hips and butt,” Bennett said. “A lot of the surgeons in the Dominican Republic, that’s what they do really well.”

Hector Cabral, who practices at the International Center of Advanced Plastic Surgery (CIPLA) in downtown Santo Domingo, is known for sculpting impossibly voluptuous bodies. Like Contreras, Cedeño’s doctor, he has a large following on social media, a tool which is heavily utilized to advertise their work and recruit new patients.

Contreras and Cabral are also known for the nine combined times they have made headlines after patients died on their operating tables.

Contreras’ clinic was shut down two days after Cedeño’s death by the national prosecutor’s office, only to reopen four months later. In a radio interview with Radio Zol FM in June 2015, Contreras admitted that there were three more accusations made against him from the families of three other patients who had died after surgery with him since 1999. He said that Dominican authorities declared no medical malpractices in those deaths. Contreras added that until Cedeño’s death, he had performed more than 20,000 surgeries.

Thirty minutes away from the posh hills of Arroyo Hondo towards the city center, CIPLA was shut down not as a result of a death during surgery, but due to a bacterial outbreak in July 2017 in its operating rooms that infected 32 Americans, three of them New York City residents.

A study last year by the American Society of Plastic Surgeons noted that between 2003 and 2017 there were 29 cases of postoperative infections in the Dominican Republic, compared to just three in Mexico – the second country with the most cases of plastic surgery tourists.

In May, health authorities closed CIPLA again after a Dominican native, Altagracia Diaz, died during a breast reduction surgery with Cabral, becoming the fifth woman – three of whom are from New York – to die in Cabral’s care since 2013. It has not reopened. There is one other known case this year of a death of a Dominican native – Julia Arias, who died after receiving a procedure in January in Santo Domingo.

On his Instagram account, which has more than 270,000 followers, Cabral publishes client testimonials and highly stylized before and after photos. Like Contreras and other doctors, he refers to his past clients as his “dolls” or, in this case, “Cabral barbies”.

Thousands of pictures of women show them with the camera focused on their new breasts under tightly stretched tops or flaunting their new hips as they bulge out from under bikini straps. The comments section of each post turns into a tug-of-war for likes between those who say his surgeries are dangerous and those who swear by his work.

But Cabral’s recruitment has not always been limited to just social media. In 2011, Cabral pleaded guilty to charges from the New York attorney general’s office that he treated patients in upper Manhattan without a state medical license on at least 10 different occasions. According to the attorney general, Cabral offered medical consultations to women in beauty salons in Washington Heights as a recruiting tactic. As part of his punishment, Cabral had to pay more than $23,000 in restitution to ten clients, a $5,000 fine and he was barred from obtaining a New York medical license for three years.

Cabral had been suspended from the local regulatory board since 2015, but was still able to practice, which illustrates the lax rules in the country

In a crowded press conference in May following Díaz’s death, Cabral appeared unapologetic and stated, monotonously, that she had “an unexpected event” at the beginning of the operation and doctors unsuccessfully tried to revive her in intensive care. In the press conference, an unprompted Cabral said he never tried to flee the country.

The Dominican Society of Plastic Reconstructive and Aesthetic Surgery, the local regulatory board that oversees the industry, told a local news station that Cabral had been suspended from the association since 2015. Cabral was still able to practice since he was registered with the country’s health ministry, which illustrates the lax rules in the Dominican Republic. (The Guardian called and sent messages to Cabral on several occasions. He did not answer or respond.)

Cabral’s suspension came one year after New Yorker Rachene Hutchinson went into surgery with him and never came out.

In July of 2014, Hutchinson, a mother of five from Long Island who frequented the island with her Dominican partner, traveled to Cabral’s clinic for a “mommy makeover”: a combination of surgeries that usually involves reshaping the breasts and abdomen following pregnancy. She died from a build-up of fluid that compresses the heart. Her mother, Diane Shields, posted her death certificate to a Facebook account which divulges details about her daughter’s death and warns others about Cabral.

At the end of June, Dominican health officials passed new plastic surgery regulations for the country’s 56 clinics. Most notable is a new resolution that requires cardiovascular and preanesthetic assessments to be done before surgery. In addition, it recommends foreign patients wait 48 hours after their flight before going into surgery due to the air pressure, and at least another three weeks after the surgery to return on intercontinental flights. A 2015 resolution laid the ground rules for surgeon qualification requirements, but this is the first time that such specific preventative measures have been passed.

The new health code includes increased sanctions against any doctor or clinic found to be guilty of medical malpractice. Clinics that are closed down, like CIPLA, will need to pass a health ministry-approved improvement plan to reopen.

If potential patients were starting to grow weary of the number of deaths over the last six years, these new regulations may encourage them to think conditions are safer. Or maybe there was never a slow down in the pipeline anyway, even for those directly affected by the industry’s flaws.

“The pain is always there, it will always be there,” Kendra said. “I feel like you just learn how to live with that pain.”

But Kendra underwent surgery in the Dominican Republic herself this May, even though she had once promised herself she would let go of her long-held desire to get plastic surgery after her sister’s death.

“I guess it’s just something like insecurities,” Kendra said. “I just want to make myself feel prettier.”