Convinced that her looks were deserting her, Kathleen Kelly Cregan took a decision that - only a few years ago - might have been unthinkable for a farmer's wife with two children in the west of Ireland. She would get a facelift and she knew precisely who would do it: a high-profile plastic surgeon in Manhattan she had read about in the papers.
An ambitious dream, but determination paid off. Inquiries to the doctor's website got a quick response and, before she knew it, Mrs Cregan was on a plane to New York and the surgery on her face was completed the same evening she arrived.
She had not, meanwhile, told the rest of her family any of that. Perhaps she was feeling a touch of embarrassment. More likely, she wanted to give her husband a grand surprise on her return.
That was not to be. The adventure of Mrs Cregan turned into tragedy. After the operation, and within three days of arriving in America , she was dead. It is a calamity that plunged a family into despair and directed a cold spotlight on an industry that profits from the insecurities of unflattering middle age. It has led to an investigation into the operation and the doctor, whose reputation may not be as glowing as his website suggests.
The phone call to Liam Cregan came on 15 March, the day after Kathleen had gone off to what she had told him was a business course in Dublin. The voice on the other end was a diplomat at the Irish consulate in New York. Your wife, he said, is critically ill in a Manhattan hospital and you must come at once. Liam naturally thought they had made a mistake. She couldn't be in America, let alone at death's door. They hadn't made a mistake.
Also in the dark was a sister of Mrs Cregan, Agnes Kelly, who lives close to Boston. Much of what we know of what happened in the Central Park South clinic of Dr Michael Sachs comes from her. While lawyers have advised Ms Kelly against talking, pending an investigation by the New York State Health Department, she has spoken just to a few newspapers, notably The New York Times and The Independent.
All seemed to go well during the surgery and, when it was done, a nurse led Mrs Cregan to a recovery room in the clinic. Then, shortly after dawn the next morning, the patient complained she was feeling dizzy. Within minutes, she collapsed suffering from cardiac arrest and was rushed to the nearby St Luke's-Roosevelt Hospital. There she was soon declared brain dead.
On 17 March, St Patrick's Day, with Liam and Agnes at her bedside, she was removed from life support. She was 42 years old. Left behind and now in the sole care of Liam are two young sons, six-year-old Eoghan and eight-year-old Brian.
Liam and Agnes have been groping for answers ever since. How did Kathleen latch on to Dr Sachs in the first place? Why didn't she take the time to scratch beneath the surface of his self-promotion? Then she would at least have seen the less glowing side to his reputation - that he has been the target of a slew of malpractice lawsuits and last year he was banned from doing some procedures without the oversight of other doctors.
A first clue was an article clipped from The Sunday Independent that they found in Mrs Cregan's bag. It was an uncritical profile of Dr Sachs, describing him as "a leading cosmetic and facial reconstruction surgeon" in New York with a "highly confidential client list".
The journalist had been given permission to shadow the progress of another Irish woman who crossed the water to benefit from the doctor's handiwork.
Dr Sachs, it transpires, actively began courting patients in Ireland in 2002, doing interviews and appearing on television. He claimed during an appearance on the Irish television programme, Ireland AM, that he had performed 42,000 rhinoplasties, or nose-jobs, during his career. On another occasion, he told the Irish Examiner that most Irish plastic surgeons "wouldn't be allowed to practise for five minutes in New York".
Mrs Cregan, who worked as a clerk for the city of Limerick, was one of the women seduced by his image. She had sent him an e-mail describing her distress. "I am 42 years old but look 56 to 58," she said. "I have become very self-conscious when meeting people."
She had one lucky break. Dr Sachs said he would be in the west of Ireland in February for a charity event. If she met with him there, she could have the surgery for a cut price of €15,000 (£10,000). She agreed, the money was handed over and the March date was set. She thought she was in good hands.
"I want to make this public because, from now on, anyone walking into the office of Dr Sachs needs to be informed," Ms Kelly told The Independent, explaining her decision to talk. There is more - or less - to Dr Sachs than was obvious to Mrs Cregan.
Five years ago, the New York Daily News included Dr Sachs on a list of the most sued doctors in the state. Since 1995, he has contended with 33 malpractice lawsuits filed against him by disgruntled patients.
All have been settled out of court for a total amount of about $3m (£1.6m). In one instance, a woman complained he left a swab in her sinuses after an operation that led to an infection.
Another claimed his botched work caused the collapse of her nasal passages. The article prompted the authorities to investigate a case where Dr Sachs had performed 16 surgeries on one patient. It was that case that prompted them to insist on the presence of other doctors when Dr Sachs undertakes complicated nasal procedures.
Meanwhile there is the doctor's website, with all of its impressive claims and references. It boasts of his directorship of the "Sachs Institute" in New York and his affiliation with the prestigious New York Eye and Ear Infirmary. In fact, the Institute appears to consist only of himself and his clinic in Manhattan.
The New York Times reported that a former assistant to Dr Sachs, Dr John Grillo, an anaesthesiologist, left his clinic in 2002 after six years because of his alarm at the high turnover of patients - up to 10 a day - and apparently lax attention paid to post-operative care. "I wasn't comfortable working in an environment with so many lawsuits," he told the paper. "In my opinion, he lost his compassion. I don't think he cared."
The suggestion of an almost factory-line approach was denied by Dr Sachs. But his standing with his peers seems not to be what most doctors would like. Dr Scott Spear, president of the American Society of Plastic Surgeons, commented that Dr Sachs "is not a surgeon of high professional standing", while his website is "full of puffery, self-aggrandisement and not professional". For his part, Dr Sachs remains certified by the American Board of Otolaryngology and continues to work. His future rests with the investigation underway inside the State Health Department, unlikely to be completed for another two to three months.
Provisional first results from an autopsy on Mrs Cregan have been inconclusive. "Without a doubt it's a tragedy," the doctor said. "We did everything we could to treat her with as much care, respect and love as we could." The doctor's lawyer, Jay Butterman, insisted his client could not be held responsible for a death that may have been the result of a pre-existing and undisclosed, or undiagnosed, heart condition. Ms Kelly, who is a nurse, prefers to keep her counsel, at least for now, about Dr Sachs. However, she cannot help but express bad feelings about a meeting she and Mr Cregan had with him when her sister was dying. She describes a man apparently unable, even under such distressing circumstances as those, to desist from his normal patter of self-congratulation. "He was just very much into himself," she confided with frustration. "And we didn't feel we got any of our questions answered."
She hopes, however, that if nothing else, women will now think twice before submitting themselves to his care.
The extent of his marketing push on the other side of the Atlantic is evident on his website. It offers links to reverential articles about himself not just in numerous American publications, including The New York Times and The New York Observer, but also European titles such as the Daily Mail and The Times.
The new willingness of Irish women to seek plastic surgery is confirmed by Wendy Lewis, a well-known plastic surgery consultant in New York whose columns have appeared in the Daily Mail and elsewhere.
The phenomenon is explained partly by the country's new economic prosperity as a fast-growing member of the eurozone and the ebbing of old taboos about attention to looks and to vanity.
"It's definitely a trend," Ms Lewis told the Irish Echo newspaper in New York last week. "I get a lot - a lot - of e-mails and letters and calls from Irish women". Many turn to doctors in America, in part because of the belief they will be better at their trade and more often because their rates are below those of clinics in Dublin or in London.
As part of her deal with Dr Sachs, Mrs Cregan was also promised accommodation in a Manhattan apartment, with nursing oversight, for the few days of her expected recovery.
The case of Mrs Cregan, however, may now put a chill on plastic surgery pilgrimages from Ireland to New York. At the very least, it may encourage would-be patients to research their chosen doctors with greater care.
"This case is a tragic event," Ms Lewis added. "But surgery has risks and it's a long way to travel. I think this might discourage a lot of people and scare them." Even more uncertain are increasing numbers of plastic surgery package deals available to women in Britain and Ireland, which involve flights and accommodation, as well as time under the knife, in places such as Malaysia, South Africa and Costa Rica.
The question about why exactly Mrs Cregan died in New York remains unanswered. The funeral in Ireland is over - Mrs Cregan's body was released after the autopsy - and adjusting to her absence is the first priority.
The burden falls first on Mr Cregan, the farmer and part-time plumber. "Liam is trying to deal with the boys," says Ms Kelly. "With being a father and a mother at once, as well as dealing with everything else that is going on."Reuse content