by Ann Rule
If gallbladders could be removed through the navel, why not use that route to insert breast implants? Board-certified plastic surgeons were having success with the navel approach. Anthony visited one physician in the Southwest and observed a few of the navel-to-breast procedures. He returned to Buffalo, convinced that he was fully prepared to add this new technique to his practice.
And, in this case, “practice” seemed to be the correct word. An article by one of the pioneers in this new surgery discussed both its positive and its negative aspects. He maintained that, using TUBA, most of the common dangers in any plastic surgery—bleeding, infection, and poor healing—were less likely to occur than in implants placed through larger incisions. However, he warned, “What is the greatest danger from (any) breast implant surgery?Having it done by someone who is not qualified to do it. Many doctors not certified by the American Board of Plastic Surgery are taking quick weekend courses about breast augmentation, including the through-the-navel method, and then just doing it. It is possible for a patient to die from any type of anesthesia and any kind of surgery. Every person should check out the qualifications of the surgeon and the anesthesiologist.”
The physician who authored the article recommended that even a very proficient surgeon who wanted to learn TUBA had to be prepared to take an intense and comprehensive training course that lasted a full week. It wasn’t something that could be done in a weekend of observation. Surgeons who used TUBA also had to be very skilled at using an endoscope, an internal instrument whose workings could be observed only through a magnified video image. The surgeon had to be able to do this without looking at his hands. “This is an ability that not all surgeons happen to have—even some skillful ones.”
But Anthony Pignataro didn’t want to take a whole week away from his office; he couldn’t afford to close it down that long. He counted on doing at least three surgeries every week. And he continued to maintain an almost miserly budget in his office surgeries, still believing that anesthesiologists were unnecessarily expensive. After giving sedatives in the form of pills before surgery, Pignataro used his own concoction of intravenous anesthesia: sodium pentothal (known to many people as “truth serum,” and Versed, a narcotic similar in action to Valium.
He could start the solution flowing into his patient’s vein himself, and then have a member of his staff inject more into the line when he felt it was needed.
He used only the most basic machines to monitor his patients during surgery. A pulse-oximeter device to show the percentage of oxygen in the blood would be clipped over the end of a finger. If the pulse-ox reading dropped too low, an alarm would sound. A blood pressure cuff would indicate if the pressure fell dangerously low. Both of these were routinely used in hospital operating rooms. However, anesthesiologists also keep track of the heart rhythm and stability with an EKG (electrocardiogram) and maintain an airway in the throat so that the anesthesiologist can breathe for the patient if that should become necessary.
There is no way to know how many TUBA operations Anthony performed in the late summer of 1997. Apparently, they took place without incident. His operating room staff was sparse at best. Janie Krauss* was twenty-two years old, a recent graduate of a vocational training school. She was not a registered nurse. She was a licensed practical nurse with very little experience. Tom Watkins* was seventeen, a high school junior at Nichols School, who was interested in becoming a doctor someday. Anthony allowed him to dress in scrubs and a mask and observe operations, paying the teenager the minimum wage—around $5 an hour.
Debbie Pignataro sometimes served as Anthony’s third assistant. She was not a nurse, a nursing assistant, a licensed practical nurse, or an anesthesiologist, but Anthony told her she was fully capable of the tasks he assigned to her. He was a medical doctor, after all. He felt supremely confident in his own ability to teach his pieced-together staff what they needed to know to help him.
Usually, Anthony didn’t know his patients all that well. The women came to him with their worries about being too fat or too flat-chested. The men came because their scalps were shining through their thinning hair. He didn’t know about their spouses, their families, their jobs—and he didn’t care. He was providing a service. He might see his patients once in a preoperative appointment, again as they lay stuporous on the table below him, and once more for a postoperative visit.
Sarah Smith was prettier than most of his patients: a very slender woman with porcelain skin, clear blue eyes, and blond hair. She came to see Dr. Pignataro because her husband’s younger sister had a roommate who recommended him highly. He had performed plastic surgery on her, and she was completely satisfied with her new and fuller breasts. That roommate was Janie Krauss, now Anthony’s L.P.N.
Seven months earlier, in January 1997, Sarah had undergone some plastic surgery on her nose to fix a deviated septum and her surgeon had also removed a small bump on the bridge of her nose. That operation was completely successful, and she felt generally confident about having more surgery done.
To anyone else, Sarah looked flawless. At 26, she was a lovely and vibrantly happy young woman. Her husband, Daniel, couldn’t imagine that anything might make her more appealing to him. He had loved her since she was 14 years old.
Sarah was born Sarah Grafton on May 14, 1971, in Springville, New York. Sarah Grafton and Daniel Smith had grown up in Springville, a town of four thousand people on the Cattaraugus River between Buffalo and Jamestown. Her mother, Barbara, came from a family that had lived there for several generations. Her father, Russell Grafton, remembered her as “Sarah—just Sarah,” but his eyes filled with tears as he recalled a “bouncy” little girl full of energy and curiosity.
Most parents will agree that each baby has its own little personality, recognizable even at birth. Sarah was a sunny, happy baby, who slept through the night from the beginning. It was fortunate that she was so easy to care for, because her parents were about to face crushing news. When Sarah was six weeks old, they took her brother David, who was four, to Children’s Hospital in Buffalo for testing. The news confirmed what they had feared. David had a progressive disease: muscular dystrophy.
Because David needed so much care and attention from her mother, Sarah sometimes resented him—but she loved him, too. David couldn’t do chores, so Sarah had to do them all. “She never complained about this role thrust upon her,” Russell Grafton said. “She became David’s friend, confidante, and protector.”
Her parents divorced in 1979 when Sarah was eight. Shortly after the divorce, Russell Grafton lost his job in the Buffalo area and was forced to move to Iowa for another position. Her mother had to work, and Sarah pitched in to help. Her father managed to visit Sarah and David every month or two for the next few years until the children became accustomed to his being gone. They always kept in close touch by phone.
Sarah did well in school, although her report cards sometimes noted that she was more interested in her social life than in studying. In the fifth grade, she took violin lessons, and she practiced faithfully all through high school, playing in the school orchestra at Springville-Griffith Institute. She had lots of friends, but she always had time for her brother, David, who was now in a wheelchair.
During her senior year at Springville-Griffith, Sarah was thrilled to be selected as a cheerleader for the basketball team. There were a lot of boys who would have loved to date Sarah, but she never really looked at any of them after she started dating Dan. He was a junior and she was a freshman when they began to go steady. Sometimes high school romances do last, and Sarah and Dan’s relationship was like that. Although they had occasional short arguments, they went to every prom and every football game together. They were as welcome in each other’s homes as they were in their own. They took Sarah’s brother to the movies with them, and the three of them often sat around talking about music. David was a special part of their lives. Sarah wouldn’t have fallen in love with anyone who wouldn’t feel compassion and responsibility for her brother.
“It w
as harder for Sarah growing up because her brother was sick,” Barb Grafton said, “but it made her a more compassionate and responsible adult.”
Dan was one of Tim and Sandy Smith’s four children—Laura, Dan, Paula, and Matthew. When the Smiths moved away from Springville, it meant a 45-minute drive for Dan to see Sarah.
“People were always predicting that we wouldn’t last,” Dan recalled. “They said when we lived that far apart, we’d break up pretty soon. But we kept dating. When I went off to college, they said we’d drift apart, but we kept dating. They didn’t understand that nothing was going to break us up. We kept beating the odds. I called her my ‘All American Country Girl,’” Dan said, “because Springville was mostly dairy farms, and Sarah just looked like a pretty, kind of old-fashioned girl.”
Sarah’s brother David went to Edinboro University in Pennsylvania, but he didn’t live to see his graduation. His health failed, and he died on February 12, 1990.
It was a sad spring, but Dan and Sarah were married on June 12. They got a little apartment in Lancaster, New York, halfway between Barb Grafton and Tim and Sandy Smith. When their first baby, a boy they named Nathan, was born, they started talking about the day when they could buy their own house.
Nathan bonded strongly with his mother. “He bonded to me, too,” Dan remembered. “But there was something special between him and Sarah.”
Every year that they were together, Dan and Sarah celebrated that fact. “We still felt as though we were beating the odds when we saw how many couples we knew were breaking up. We toasted each other every year. We were soul mates, and we knew it.”
Sarah was the optimist of the pair, and Dan admitted that he tended to look at the negative side of things. “She gradually taught me to look on the bright side—she was always positive.”
Dan was very tall, broad-shouldered and handsome, and strangers might have found Sarah a little docile at first because she was quiet. “But she was feisty,” her mother-in-law, Sandy, recalled, “and she was very strong emotionally. They decided what they wanted out of life together.”
Dan worked as a drafter/designer, and Sarah began work as a courier for a law firm. She had always been fascinated by the law and hoped to be a paralegal one day. Both Sarah and Dan worked full time, and he had his own business that he’d started in college: custom crating for companies that wanted to be sure their products, mostly heavy machinery, arrived in good shape.
“We called it ‘DSS’ for Dan and Sarah Smith,” Dan said.
By August 1995 they had saved enough for a down payment on their first home. Sarah did most of the leg-work on the legal documents they needed, and it saved them some money. It was a “starter” house in Depew, New York, another hamlet near Buffalo, close to Williamsville, where Debbie Pignataro grew up, and near the Buffalo-Niagara International Airport. It had three small bedrooms and a bath-and-a-half, and even though it looked like millions of other houses where young couples start out, Dan and Sarah were thrilled because it was theirs.
Dan built a shed in the back, and Sarah discovered that she loved gardening. It wasn’t a very expensive landscaping project, but it looked great, and Sarah took great satisfaction in it.
“Our home was our hobby,” Dan said. “We fixed it up outside, and Sarah planted flowers. There was a whole section in the backyard where she planted packets of wildflower seeds. We called it our potluck garden because we never knew what was going to come up. Daisies were her favorite flowers.”
Three years after Nathan’s birth, Amanda was born. “Nathan was like his mother,” Sandy Smith said. “Thoughtful and strong, too. He was his mother’s son, and he thought she was the most special mother in the world. When Sarah had Amanda, she was a miniature version of her mother. But Amanda’s emotions were more on the surface.”
Dan and Sarah’s time off work was spent with their children, their parents, and good friends. “Friday nights were special to us,” Dan said. “We rented kids’ movies and made popcorn, and we all bundled up in blankets on the living room couch. We usually fell asleep there. Sometimes, in the summer, we went for drives on Friday nights.”
Nothing interrupted those family nights. They also loved to go over to swim in the elder Smiths’ pool and share a barbecue. They spent Christmas Eves with Sarah’s mom, Barb, and then went to Dan’s parents on Christmas Day. Dan loved his mother-in-law. Although Sarah’s father had married again and lived in Iowa, Sarah remained close to him. Russell Grafton called her every second Sunday, and they visited back and forth.
Dan was proud when they entertained several of his friends, and the men commented on what a wonderful wife he had. “They told me I was so lucky because she was such a great person, and I knew I was lucky,” he said. “She was young, funny, vibrant, and outgoing. She just put a smile on your face.”
They argued sometimes. Dan and Sarah didn’t have a perfect marriage, but they came close. “We just believed that you should work things out,” Dan said. “We always figured that marriage was what you put into it.”
Chillingly, they had a few somber conversations that might have surprised people who knew them. “We’d only been married a year or two,” Dan said, “and we started talking about ‘What if? What if one of us would die; how could the other one go on? I remember that we asked each other what we would want for the one that was left.”
Sarah told Dan that her biggest fear was that he would be miserable without her. And how would he take care of Nathan and Amanda? “Don’t stop living,” she told him. “If I wasn’t here, remember that I would want you to go on and be happy. I’d want you to find somebody to love.”
And then she laughed. “And if you found the wrong one, I’d let you know before you married her. I’d drop a drink in your lap or something to get your attention!”
* * *
Dan’s parents, Sandy and Tim Smith, used to feel blessed, too, by their good health and their four kids, who had turned out well. Then, in the spring of 1997, Tim suddenly became very ill. For three weeks, doctors couldn’t diagnose what was wrong with him. His kidneys weren’t functioning as they should. Finally, they honed in on Wagner’s disease and were able to get him stabilized.
It made them all realize how vulnerable they were to the vagaries of fate—that there were no guarantees for them, or for anybody. They cherished their family all the more. They all felt as if they had dodged a bullet.
Dan and Sarah had a big project the summer of 1997: they worked together to remodel their bedroom. “We steamed off the old wallpaper,” Dan said, “and sanded everything down, put up new wallpaper, and painted. Sarah used stencils to paint designs, and we got some bedside tables. We didn’t spend that much. It was mostly our own work we put into it.”
The elder Smiths had always welcomed foreign exchange students into their home. “We had them from France, Spain, Peru, Ecuador, Germany, and Russia,” Sandy laughed, “all through the years after our own kids were grown.”
The 1996–1997 students were from France, and they were due to go home in the third week of August. As usual, Sandy and Tim Smith threw a big farewell party for them out by the pool, with the requisite barbecue.
“It was on August 16,” Sandy remembered. “Sarah was on the pool deck in her bathing suit, and she looked beautiful. But she always wanted boobs. For six years, she’d been talking about having breast implants. She used to ask me, ‘How can I have two kids and no boobs?’ And I’d tell her she had a beautiful figure, but she never believed me. It didn’t matter to Dan. In fact, he didn’t want her to ever have surgery because he worried about her.”
No one looking at Sarah Smith could have imagined that she felt unhappy about her appearance, but perfection had become a goal of many young women in the nineties, bombarded as they were by images of movie stars and top recording artists. Most of them didn’t realize that most of the exquisite models’ and stars’ photographs were air-brushed to remove the slightest flaw and that expert makeup artists worked over them for hours. Sarah s
tared at her modest bustline and felt inadequate.
There had been a medical reason for her nose surgery. There was no reason at all for her to have breast implants—nothing at all beyond Sarah’s own perception that she really wasn’t very attractive.
When she got a job promotion six months earlier, her salary was enough so she could save for the operation. She wouldn’t have taken money meant for her family, but now she had enough to pay for it.
When Sarah had her first appointment with Dr. Anthony Pignataro, she was impressed. He told her she was a good candidate for the new surgery he had perfected. Since everything had gone so smoothly with her nose surgery in January, Dan wasn’t worried about Sarah’s operation, although he still didn’t see any need for it. She explained to him that Dr. Pignataro had told her about a brand-new procedure that he was using. “He said it worked so well that he would be charging more for it soon—but he would give her a special price,” Dan said. “He talked to her the way a salesman talks.”
Dr. Pignataro noted on Sarah Smith’s chart that he had given her a complete physical examination, although he did not do any X-rays or give her an EKG, explaining that it wasn’t necessary because she was under forty. He did take all the requisite blood tests, and he advised her hurriedly of the possible dangers in surgery. She signed releases, and her surgery was scheduled for 9:30 on the morning of August 25, 1997.
Few people knew that Sarah had made an appointment to have her breasts enlarged. “She told me and her mother, of course,” Sandy said. “And her sisters-in-law, but she wasn’t the type to tell people she wasn’t really close to.”
As Sarah enjoyed the barbecue party for the French exchange students that Saturday night, Sandy noticed that she was “super happy. She came over to me and whispered, ‘Take a good look because this is the last time I’ll look like this in a bathing suit!’”
Sandy forgot about that conversation soon after the party when Tim Smith suddenly became very ill. He was taken to the hospital and they were all afraid that his earlier illness had returned, but it was only his gallbladder. He was home by Tuesday, August 19.