MIAMI – Just after dawn, the women arrive. 

They come in taxis and rental cars, to a strip mall clinic tucked between a barber shop and a discount shoe store. 

They fly in from across the country for deals they can’t get back home – thousands of dollars off cosmetic surgeries, available, if they like, on payment plans. 

Inside, the lobby looks like any other surgery center: polished white floors, sleek, modern furniture, a large flat screen flashing images of beautiful bodies. 

But this clinic is run like a factory assembly line, where individual doctors – many with little specialized training – line up patients and operate on as many as eight a day, an investigation by USA TODAY and the Naples Daily News has found.  

In surgeries designed to improve appearances, no one is expected to die. 

But in the past six years, the Miami clinic and a nearby facility overseen by the same doctor have lost eight patients in a spate of casualties not seen anywhere else in Florida. Together, they account for about 1 of every 5 plastic surgery deaths in the state, the investigation found. 

Nearly a dozen other patients were left with critical complications, including three with punctured internal organs, that forced them to rush to hospitals for help, medical reports and other records show.  

Many of the fatalities and injuries were not the results of unavoidable complications, but of serious mistakes and procedures that went far beyond the bounds of safety. 

Four of the women died after their doctors mistakenly injected body fat deep in their muscles and tore the veins during a popular surgery known as the Brazilian butt lift, records and interviews show. The fat pooled in their hearts and lungs, killing them in minutes. 

A 51-year-old mother from Georgia was forced to have emergency surgery after her small intestine was perforated three times during her cosmetic procedure and human waste spilled into her body. 

A 33-year-old woman who had cosmetic surgery was hospitalized after emergency room doctors discovered her liver had been lacerated, which caused her to bleed internally for days. 

Seven of the women who died were working-class Hispanics and African Americans — groups targeted by the clinics’ advertising campaigns. 

While deaths and injuries mounted, the names of the clinics were changed three times since 2016, but one person has remained at the center: Dr. Ismael Labrador.

The 56-year-old doctor, who was once suspended from practice for allowing unlicensed workers to perform cosmetic procedures, spent years building the business and burnishing a national image for the facilities, crafting social media campaigns that target women with messages that they, too, can afford body transformations.

The business is among more than a dozen high-volume clinics that have transformed Florida into a national destination for plastic surgery. 

The centers are radical departures from the cosmetic surgery clinics that long dominated the industry. 

They are owned by investors and driven by social media marketing and discount prices that attract thousands of patients each year from across the country. 

To make his business work, Labrador hired dozens of doctors who were not board-certified in plastic surgery and paid them on commission. He offered popular but risky surgeries and allowed them to be scheduled morning to night. 

Doctors were so busy in operating rooms they sometimes left patients to fend for themselves after their procedures. When severe complications arose, treatment could be delayed for days, forcing women to rush to hospitals for emergency help, medical records and interviews show. 

Because the names of the business were changed several times under Labrador’s direction, patients were often unable to connect the deaths to the business — now known as Jolie Plastic Surgery. 

When patients raised questions on websites about the deaths of women at the clinic, Jolie’s business manager denied it was the same place. 

“The fact that we took over the location where there was a previous plastic surgery center does not make us associated with the previous owners,” Dr. Amaryllis Pascual wrote on Aug. 9. 

But company websites show the same doctors remained at the Miami clinic and continued to perform the same surgeries. The same law firm — owned by Labrador’s wife, Carmen Gallardo — still represents the clinic.

Two former top staff members told USA TODAY that Labrador continues to play a key role at the facility, hiring staff and directing the marketing.   

Kizzy London was one of the patients who knew nothing about the facility’s history, said her fiancé, Edward Graves.

Her surgery to slim down her stomach and enhance her curves was a Christmas present to herself two years ago as she reached 40 and wanted to turn back the years on her body. 

The mother of two from Baton Rouge was enticed by the low prices and promises that top surgeons would be provided, Graves said. 

“She said: ‘They are good. I am reading up on them,’” he recalled. 

What London didn’t know: Other women had died in the same center before the name was changed to Jolie. 

She would be the next. 

A Miami plastic surgery empire attracted patients from across the U.S. with the promise of inexpensive procedures and life-changing results. Eight women died.

Little oversight

In the past six years, the Florida Department of Health has investigated at least a half-dozen deaths and severe injuries at Labrador’s clinics. The agency has charged at least two doctors with malpractice. It has cited the facilities more than two dozen times for failing to keep proper medical records. 

None of that stopped patients from dying. 

Though the state health department has the power to impose emergency suspensions on facilities that pose a public threat, it has not taken such action. 

Instead, state officials say they discipline the doctors who work in the facilities. 

That approach doesn’t solve the problem, patient advocates say. Unless the state cracks down on the clinic, the owner can simply bring in new doctors and carry out surgeries that lead to more casualties. 

Labrador canceled an interview with reporters in July, citing a family medical emergency, and did not respond to further interview requests. In written responses to some questions, he defended the business he founded a decade ago. 

He said doctors – not clinic owners – are responsible for patient care and free to establish their own course of treatment before, during and after surgery.  

“The surgeons ultimately approve and make decisions concerning their schedule, how many and what kind of procedures will be performed by them each day,” he wrote. 

He said all the doctors he hired met requirements of the state licensing board. 

“I am not the one who makes the decision whether the doctor is ready or legally and professionally able and capable to operate,” he wrote. 

Florida courts, however, have found that medical facilities – not just doctors – are directly responsible for the deaths and injuries of patients. 

“The clinics run the operation, advertise the procedures, charge the patient the money and provide support medical staff,” said Andy Yaffa, a Miami attorney who lectures on malpractice law in seminars across the country. “They are in this together.” 

Police sting

Labrador’s rise in plastic surgery began as the industry was undergoing sweeping changes. 

A Supreme Court decision lifted a ban on physician advertising in 1982 and opened the door for a new style of clinic. Doctors no longer needed to build a reputation over years by word of mouth. With low prices and advertising, they could build a business virtually overnight. 

Social media sped up the transformation, and Labrador’s clinics were among the first to leverage the reach of Facebook, YouTube, and Instagram, helping turn Miami into a major center for cosmetic procedures. 

Labrador used those new tools to remake himself and his career. 

Two decades ago, he faced bankruptcy over tens of thousands of dollars in credit cards and other debts. When he filed for court protection in 1999, he listed a Toyota Corolla as his most valuable asset. 

By 2007, he had earned his Florida medical license and was running his own cosmetic centers in blue-collar areas of Hialeah and suburban Miami, offering procedures such as tummy tucks and eyebrow surgeries. 

But he soon got into trouble. 

Acting on a tip, police launched a sting and charged him with allowing workers with no medical licenses to inject chemical filler into the faces of patients to remove wrinkles – a procedure that can cause blindness if not properly done.  

Six months later, he was charged again, this time with hiring a foreign doctor without a U.S. medical license to perform invasive surgeries on women, including vaginal reconstructions. 

Under an agreement with prosecutors, he entered a court diversion program and his felony charges were dropped in 2010.

By the time the Florida medical board took up the case that same year – placing him on probation for three years and fining him $30,000 – Labrador was ready to expand his business and launch an ad campaign that would span the country. 

Selling dreams

Today, ads for Jolie can be found in every corner of social media. 

Many messages are the same: We know what it takes to make your body beautiful. And we will help you get there. 

“Trust me,” one jingle says in Spanish. “We’re going to make you happy.”   

To help sell the surgeries, telemarketers take calls and answer online queries in offices above the clinic.

Some of the most popular procedures are designed with an ideal of beauty – large, round curves and buttocks – intended to appeal to a younger generation, especially Hispanics and African Americans. 

To entice women to sign up, the clinic flashes before-and-after images of sagging, overweight bodies next to curvaceous new ones. 

The clinic promotes the individual doctors and their stunning results in social media ads that have attracted national followings. 

Some of the patients who have undergone surgeries with Dr. Jonathan Fisher call themselves “Fisher dolls” on social media. In the case of Dr. Anthony Hasan, they call themselves “Hasan dolls.” 

Cut-rate prices are front and center in the promotions: $3,500 for a tummy tuck, $4,000 for a butt lift – half what traditional surgeons charge. 

Labrador makes ends meet by hiring doctors willing to work on commission and giving them about 30 percent of the business they generate. 

“The only purpose is to do more and more and more,” said Bernabe Vazquez, a plastic surgeon in Miami for three decades. “It’s crazy. It’s not a patient-doctor relationship anymore. It’s a business.” 

By 2016, Labrador’s business was booming. After years of financial struggles, he had now founded three clinics.

He had traded his Corolla for a Bentley and bought a sprawling South Florida compound with a 6,597-square-foot home. Valued at $2.4 million by Miami-Dade County, the property includes stables and a training area for horses. 

“He took it to another level,” said Andres Beregovich, a Florida lawyer who investigated the clinics for patients who say they were injured. 

‘Pray for me’

Heather Meadows was a typical client for Labrador.  

At 29, she was a single mother raising two small children in the foothills of West Virginia. Her mother was a clothing store clerk; her father, a union millwright.  

She earned $11 an hour at an employment agency. At night, she took business classes at Bluefield State College just miles from her home. She was looking for something better for her kids. 

After two pregnancies and changes in her body, she was looking for something better for herself, too.  

She heard about Labrador’s clinics from a friend and started making plans to tap into her federal tax refund to pay for a $3,500 Brazilian butt lift. 

A wave of popular culture driven by rap stars and TV celebrities helped transform the procedure into one of the fastest-growing in the nation. Using a long, thin tube, doctors suction fat from the abdomen and other areas, and then inject it into the buttocks to enlarge them. 

In most cases, the procedure can be done safely by well-trained physicians. But it’s considered the most dangerous in cosmetic surgery, with an estimated death rate of 1 in 3,000 operations. 

The risk comes if doctors inject fat into the muscle – an area they are warned by experts to avoid – and tear open veins. There, the vessels can carry the fat to the heart and lungs, which creates a deadly blockage known as an embolism. 

Meadows knew there was some risk. And what she found when she arrived in South Florida raised even deeper concerns. 

The clinic was in the back of a strip mall. Her doctor failed to show up for their first meeting. And she learned that one of the clinic’s top doctors, Osakatukei Omulepu, had recently been accused in a state malpractice inquiry of critically injuring two patients at another facility where he worked.  

“Pray for me, Suzy, please,” she nervously texted a friend while she waited to go to an operating room. Then she was under anesthesia. 

In just 55 minutes, her surgeon, Dr. James McAdoo, finished the operation in less than half the time it was supposed to take, state records and experts said.   

As she was being wheeled to the recovery room, Meadows awoke briefly and lifted herself up on the gurney. But something was wrong.

Dangerous workload

Labrador would not say how many procedures his doctors perform on a typical day. But court documents and other records show two of the top surgeons were doing up to eight – double the number that many experts consider safe. 

One of them earned $33,000 in just five days after carrying out more than two dozen, according to a compensation lawsuit in 2014. 

For most surgeries, the number of procedures a day should be four to make sure doctors don’t get fatigued and make mistakes, said Dr. Grant Stevens, president of the American Society for Aesthetic Plastic Surgery. 

Florida’s health department inspects everything from surgery office registrations to the cleanliness of surgical tools in the clinics. But when it comes to the number of procedures a doctor does in a day, the agency says there’s nothing it can do.  

The state leaves it up to the physicians to monitor their own time, said Brad Dalton, an agency spokesman. 

Two medical experts who reviewed injury cases from the clinics for USA TODAY said the damage that was inflicted – including three cases of punctured organs – were the result of poor training, shoddy surgical techniques, or both. 

TIPS: Before scheduling a cosmetic surgery procedure, make sure you follow these 14 steps.

Perforating intestines with surgical tools requires enormous force that cannot be explained by a minor mistake, said Adam Rubinstein, chief of plastic surgery at Jackson North Medical Center in Miami.

“It’s indefensible,” he said. “Do you have any idea the kind of force it takes to break the abdominal wall?”  

The heavy workload carried by some of Labrador’s surgeons raised concerns in other ways, as well.  

A half-dozen patients told USA TODAY that they sat in crowded waiting rooms for hours while others, like Meadows, did not meet their doctor until just before their operations.  

And when serious complications arose after surgeries, at least eight patients said they struggled to get help, according to interviews and lawsuits. 

Ivis Beracierto showed up at the Hialeah clinic with pain and open wounds three times in 2016, but was sent home and told to take antibiotics.

In frustration, the 48-year-old woman went to Jackson Memorial Hospital – her wounds turning black and oozing pus – where doctors found gangrene had spread through her abdomen and ordered emergency surgery, hospital records show. 

In another case the previous year, two women were hospitalized with complications a day apart and required emergency blood transfusions after surgeries with Dr. Osakatukei Omulepu, according to a state health department probe.  

When medical workers tried to contact the 46-year-old doctor to talk about a course of treatment, he could not be reached, witnesses told state agents. “My daughter almost died,” said the father of one of the women.  

For two days, one of the hospitals tried unsuccessfully to reach Omulepu, state reports said. Omulepu said in an interview that he was never alerted by the clinic that patients were trying to call him, and that he managed to speak to a doctor from one of the hospitals by phone. 

He said the clinic did not have an answering service and that he regularly gave his cell phone to his patients. “I did not abandon them,” he said.

Stevens, president of the American Society for Aesthetic Plastic Surgery, said the lapse of time for the doctor or the clinic to reach the women — two days — was inexcusable. “They are both responsible,” he said.

The health department charged Omulepu with failing to keep proper records in both cases. But during the probe, state agents learned that two other women suffered even greater complications during surgeries with Omulepu at another clinic where he worked.

Citing the severity of those injuries – one woman’s liver was punctured five times – the state medical board revoked his license.  

No special training

As his clinics grew, Labrador turned to doctors with no specialized training to meet much of the demand. 

Of the 39 physicians who were promoted on his websites in the last eight years, 24 were not board-certified in plastic surgery – a specialty that comes after six years of residency and safety training. 

Though many states allow doctors without credentials to perform cosmetic surgery, most traditional clinics avoid it, said Dr. Arthur Perry, an author on plastic surgery safety who once served on New Jersey’s medical disciplinary board.  

The lack of specialized training at Labrador clinics is especially worrisome because of their emphasis on butt lifts, Perry said. 

“It’s a dangerous enough procedure,” said Perry, who refuses to do it.   

OPINION: I’m a plastic surgeon who won’t perform Brazilian Butt Lifts.

At least three medical studies in the past four years warned of the dangers of the surgery. And a special task force was formed in 2017 that includes two of the largest plastic surgery organizations in the country to look for ways to avoid fatal mistakes.  

Even with no credentials in plastic surgery, several of Labrador’s doctors continue to do them. 

One of his doctors who lost a patient two years ago was banned by the state from doing any more Brazilian butt lifts in an emergency order after investigators warned he could injure more people. 

They said Arnaldo Valls’ only training in these procedures consisted of a four-day workshop in liposuction and a one-day class in fat transfers. 

Valls, 75, who is also accused by the state of critically injuring another patient by puncturing her intestine, said he learned to do the procedure from assisting other doctors and has performed many butt lifts on his own. He’s contesting the state’s actions in both cases, which are set for a March hearing. 

State officials say they protect the patients by punishing doctors who make fatal mistakes during the surgery. But they say they don’t have the legal authority to take action against the clinics.

However, two legal experts say the state can suspend the clinics from operating when they pose a threat to the public.

Lauren Leikem, a former Florida health department prosecutor, said the Florida surgeon general has taken such actions against other businesses.

“Waving their hands in the air saying they don’t have the authority or disciplinary guidelines when this many patients are dying is bull,” said Leikem, now with the Chapman Law Group in Florida.

A mother’s nightmare

As Meadows was carried from the surgery room in 2016, she rose up. But almost as quickly, she collapsed and stopped breathing. 

By the time she arrived at the hospital, she was dead. 

“It was all just a nightmare,” said her mother, Tammy Meadows, who is now raising her two grandchildren, ages 8 and 2. 

“She was my best friend. She’d call me five times a day. I look at her little girl, and she looks just like her.” 

Tammy Meadows said her daughter had searched online for information about the clinic and the surgeon, Dr. McAdoo, before she went in for surgery. 

The 49-year-old board-certified physician was promoted on the clinic’s website as “having a history of providing the highest quality results to his patients.” 

But court records reveal a very different medical history. While he was practicing in Illinois, McAdoo was sued at least three times for malpractice, including one case in which a woman said she was burned so severely from an electrocautery device it left her badly scarred, court records state.

He settled two cases for a total of $750,000, and a third was settled confidentially. McAdoo denied the allegations in the lawsuits. 

During Meadows’ surgery, he made a critical mistake by tearing a vein, allowing fat to seep into her bloodstream, according to state reports and experts. McAdoo, who denied any wrongdoing and has since left the clinic, is expected to appear before the medical board on the malpractice charge.  

Family and friends recall a young woman who worked hard to make a better life for her children and tried to help others in need.   

In a part of the country wracked by opioid addiction and joblessness, she raised money for families who couldn’t pay their bills, said her friend Suzanna Wilson.  

“If she ever found out someone was in need, like diapers, formula, clothes, she would go out and buy it for them,” Wilson said. “She had a heart.”  

No trace

Tracing the history of Labrador’s clinics is not easy. Today they operate under the name Jolie Plastic Surgery. But Labrador and his staff have repeatedly changed the name, records show. 

The Miami clinic was known as Vanity Cosmetic Surgery in 2014, and the Hialeah clinic was called Encore Plastic Surgery in 2015. Both names were changed to Eres Plastic Surgery in 2016, then Jolie the next year.  

Each time the name changed, information about women who died at the clinics became harder to find on sites like Yelp, or through web searches.  

But inside, it was the same clinic, many of the same doctors, doing the same procedures at the same discounted prices. 

Labrador said name changes were part of normal business and marketing, and were not carried out to avoid any legal responsibility. 

But the timing, in some cases, provided a public relations win for his embattled business.  

In 2016, Florida’s attorney general was putting the final touches on an investigation into Labrador’s clinics. Dozens of patients had complained the facilities had refused to return deposits when surgeries were canceled.   

Two days after he signed an agreement to repay $200,000 in deposits, Labrador’s company sent an email blast to promote his newly named clinic: Eres Plastic Surgery, and a Halloween special for butt lifts at $4,000.  

Four months later, he transferred ownership of his $2.4 million country estate and horse stables to his wife, Carmen Gallardo.  

At that point, his name no longer appeared on any corporate records of the business.  

In 2017, a new president showed up in corporate records: Enmanuel Pimentel.   

USA TODAY tracked down Pimentel, 28, who works for an appliance repair company and lives in a modest rental home across the state in Lehigh Acres.

But Pimentel said he had never heard of the clinics or Labrador.  

“It’s not me,” Pimentel said.  “I don’t know what you are talking about.” 

Twelve days after USA TODAY interviewed him, clinic operators dropped him as the top officer and replaced him with a new president: Caridad Pimentel, whose only known address is listed at the clinic.  

Caridad Pimentel did not respond to phone messages left at the clinic. Labrador did not respond to questions about either Pimentel.   

Lawyers representing patients in malpractice cases argue in court filings the changes in Labrador’s business were meant to shield it from liability.  

Graves said he didn’t know anything about the clinic until after his fiancee, London, died from her surgery in 2017.  

If he had known about all the name changes, he would have urged her to cancel her operation.  

“That would have put a halt to it right there,” said Graves, who accompanied her to Miami. “Something is not right about the place.”

Instead, he said, he trusted the clinic because London told him she had been reading the advertisements. 

“Never, never did we (suspect) anything,” he said. 

The day after she died, Graves said he returned to the facility to retrieve her leather purse and cellphone. As he walked in, he noticed the waiting room filled with patients. 

Staff members were scurrying between the lobby and the rear examination rooms. 

“It wasn’t 24 hours,” he said. “They were right back in business.”   

Contact Maria Perez, now at the Milwaukee Journal Sentinel, at maria.perez@healthstationblog.comjrn.com and Michael Sallah at msallah@healthstationblog.comusatoday.com

USA TODAY investigative reporter Steve Reilly and Fort Myers News Press reporter Frank Gluck contributed to this story.