On Aug. 4, 2014, plaintiffs’ decedent Arleen Vasquez, 35, a social worker, underwent an enhancement of her buttocks, commonly known as a Brazilian Butt Lift, which is a popular cosmetic procedure in which fat harvested from liposuction is immediately transferred to the buttocks in order to enhance their contour and size. The procedure was performed by Dr. Kenneth Hughes, a board-certified plastic surgeon, at Boris Cosmetic, a credentialed surgery center in Culver City. Vasquez had previously undergone plastic surgery on multiple occasions, and in June 2014, she presented to Dr. George Boris, a cosmetic surgeon who was the sole owner and operator of Boris Cosmetic, for the purpose of undergoing the Brazilian Butt Lift. However, on the day of the surgery, Boris transferred Vasquez’s case to Hughes, who had previously performed many Brazilian Butt Lifts. Hughes had routinely done procedures at the Boris surgery center and had an ongoing financial relationship with Boris. Prior to the procedure, Hughes met with Vasquez and informed her that she did not have sufficient abdominal fat to do an abdominal liposuction as part of the operation. Thus, he changed the plan to harvesting the fat from Vasquez’s upper arms and inner thighs (medial thighs), and then flipping her and harvesting additional fat from her lower back and flanks before transferring all of the fat to her buttocks. The operation was conducted with the assistance of an anesthesiologist, Dr. Randal May, and the operation proceeded without incident. However, approximately 30 minutes after the operation had concluded, and prior to extubation, Vasquez’s still-monitored vital signs showed a sudden crash of her oxygen and carbon dioxide levels, together, with a very significant drop in her heart rate (bradycardia). May subsequently attempted to resuscitate Vasquez, but, eventually, 911 was called and Vasquez was transferred by ambulance to Southern California Hospital of Culver City, where she was provided with CPR for over two hours. She was also provided with a tissue plasminogen activator (tPA), a clot buster, because a pulmonary embolism was suspected. There was also a suspicion of pulmonary fat emboli, which can be a very rare complication of Brazilian Butt Lifts, and which is untreatable and usually fatal. Approximately four hours after the operation had concluded, Vasquez was pronounced dead. An autopsy was performed on Vasquez by a board-certified forensic pathologist, the deputy medical examiner for the county of Los Angeles, Dr. Ajay Panchal. During the autopsy, Panchal made an abdominal incision and encountered a large quantity of blood in the abdomen, which he concluded was the cause of death. He then began searching for the vascular injury, which he assumed had caused the bleed, and examined all of the pelvic organs, but found no damage to any of them. In conducting his search for the presumably injured vessel, Panchal, by necessity, entered into the retroperitoneal space, very deep in the body and on the anterior portion of the sacrum, and allegedly found a disruption, which he described as a “traumatic wound to the right internal iliac artery,” and concluded that the wound was the immediate cause of the death. During the autopsy, Panchal took 38 photographs, including external pre-autopsy photographs, depictions of the unclotted blood, and a number of photographs depicting the alleged site of the right internal iliac artery. Vasquez’s minor daughters, Madison Leon (by and through her guardian ad litem, William Leon) and Desiree Landaverde (by and through her guardian ad litem, Luis Landaverde), sued Hughes; May; Boris; and the operator of Boris Cosmetic (also known as Boris Cosmetic Center, Boris Cosmetic’s Center, Boris Cosmetic Surgery Center, Culver City Ambulatory Care Center, and Boris Cosmetic Surgical Center and Med Spa), George Boris, M.D., A Medical Corporation. The decedent’s daughters, through their respective guardians, alleged that the defendants negligently performed the Brazilian Butt Lift, causing Vasquez’s wrongful death, and that the defendants’ negligence constituted medical malpractice. Boris and his entities ultimately settled out, and May was dismissed from the case. Thus, the matter continued against Hughes only. Plaintiffs’ counsel contended that Vasquez died as a result of a “traumatic wound to the right internal iliac artery,” as reported on the autopsy report prepared by Panchal, which caused the reported blood loss of 2200 mL that was found in her abdomen during the autopsy. Counsel contended that Hughes had to have been negligent in penetrating to the level of the internal iliac artery, which was far deeper than the fat layer appropriate to the abdominal liposuction, even though it had never been performed. The plaintiffs’ plastic surgery expert acknowledged that the internal iliac artery is a very large and critical artery that would have led to a large bleed. The expert also acknowledged that the surgical/anesthesia records were accurate and that they showed that there was no change in the vital signs until 75 minutes after the alleged injury. The expert opined that the only explanation for the 75-minute delay in the change of the anesthesiologist-monitored vital signs was the development of a tamponade, in that the effect on the decedent’s pelvic organs had been sufficient to temporarily stop any bleeding from the large vessel. Defense counsel noted that plaintiffs’ plastic surgery expert originally testified at his deposition that the injury must have occurred during the “abdominal liposuction,” but that by the time of trial, the expert and plaintiffs’ counsel were aware that Hughes had not done any abdominal liposuction and that it had been explicitly deleted from the consent forms and the pre-operative records. So, the plaintiffs’ expert asserted at trial that Hughes must have liposuctioned the abdominal area from the insertions on the right and left sides of the medial thighs, which had been placed there specifically to harvest fat from the thighs. The expert acknowledged that there was no actual evidence that Hughes had made such a gross mistake, other than the asserted injury to the right internal iliac artery, but opined that the nature of the injury was conclusive evidence that Hughes had committed malpractice and that his malpractice was the legal cause of death. Plaintiffs’ counsel called the deputy medical examiner and forensic pathologist that performed the autopsy, Panchal, to testify. Panchal insisted that the cause of death was the injury to the right internal iliac artery and that it was so obvious that he did not need to examine the lungs for any possible pulmonary fat emboli even though that cause was mentioned in the coroner’s investigator’s report regarding the emergency room intervention. Panchal also insisted that he did not need to verify that the blood in the abdomen was indeed blood, and not a combination of waters introduced during the procedures and small amounts of blood that would normally be associated with that procedure. However, Panchal acknowledged that the cost of doing those additional verifying tests would have been nominal. The plaintiffs’ pathology expert, the long-time head of the Department of Pathology at the University of California, Los Angeles, and the director of autopsy services at that facility, testified that he had reviewed the autopsy photographs and had seen the actual suspect tissue that had been preserved. However, he claimed that he was unable to confirm the identity of the artery involved. Under Evidence Code § 776, plaintiffs’ counsel called Hughes to the stand and asked him a series of expert questions, even though Hughes had refused to answer such questions at the time of his deposition and had never been designated by the defense as an expert. Hughes testified that he could not have caused the claimed in the autopsy report and that the most likely cause of death were pulmonary fat emboli, which is known in the community as being associated with that operation. Hughes further testified that he had disclosed that risk in his written consent form. In addition, during his testimony under Evidence Code § 776, Hughes presented an exemplar cannula as was used by him during the subject operation. It was a 3 or 4 millimeter, blunt-end cannula of approximately 9 inches in length, designed specifically for the purposes of performing liposuction in the fat layer immediately under the skin. However, defense counsel noted that the plaintiffs’ plastic surgery expert presented an alternative cannula that was approximately 16 inches long, with a larger diameter, and a sharp end and that the expert’s cannula was admitted into evidence. Hughes’ counsel argued that Vasquez died as a result of pulmonary fat emboli, which is known to be associated with Brazilian Butt Lifts and was subsequently reported as occurring in approximately one in 1500 cases, and that Vasquez did not die of an injury to the internal iliac artery or any other vessel. Counsel noted that the internal iliac artery is located very deep in the retroperitoneum, essentially on the front of the sacrum. Thus, defense counsel argued that the alleged injury was anatomically impossible to have occurred during the subject superficial plastic surgery while using a blunt cannula, which could not have physically penetrated through the multiple organs and tissue between the skin (or the target fat layer) at the site of the alleged injury. Moreover, counsel argued that an injury of that sort would necessarily have left a pathway of destruction, as any instrument would have necessarily passed through the pelvic organs, but that there were no findings of any such . As to the longer cannula introduced by the plaintiffs’ plastic surgery expert, defense counsel argued that there was no evidence that Hughes had used that type of cannula and that the plaintiffs’ plastic surgery expert was unaware of anyone using that type of cannula for liposuctions. Thus, defense counsel contended that the autopsy was wrong and that the reported injury to the right internal iliac artery was either caused by the resuscitative efforts in the emergency department or was caused by Panchal, who, according to defense counsel, has a very poor understanding of anatomy (despite holding, among other things, board certification in anatomic pathology). Counsel further contended that the blood was likely a mixture of random blood inherent in the procedures and a large amount of water/fluids used during the operation. Defense counsel noted that the anesthesia record showed that, after the operation and as Vasquez was under the sole care of May, Vasquez’s oxygen and carbon dioxide levels suddenly crashed while the heart rate and blood pressure remained stable for an uncertain amount of time. Counsel argued that the record was definitive evidence that Vasquez was suffering from an obstruction of the lungs, which had to be either a pulmonary embolus (which is not peculiarly related to the operation) or pulmonary fat emboli. However, counsel noted that Panchal elected not to examine the lungs for pulmonary fat emboli, which are tiny and need to be microscopically observed, because of a “rush to judgment.” The defense’s pathology expert, the long-time coroner and chief medical examiner of Lubbock, Texas, opined that the autopsy performed by Panchal was incomplete and incompetently done and that the available evidence showed that Vasquez died of something other than the purported wound to the internal iliac artery. The defense’s expert also testified that the failure to obtain a microscopic evaluation of the lungs rendered the autopsy incomplete and unreliable since Panchal had refused to conduct very simple tests that would have either ruled out or shown conclusively that the cause of death was pulmonary fat emboli, which has long been known to be associated with Brazilian Butt Lifts. Hughes’ counsel contended that a 2017 study, based on a survey of a subgroup of plastic surgeons, showed that approximately one in 3000 patients who undergo the Brazilian Butt Lift procedure will sustain the same type of lung obstructions, with approximately half of those patients dying immediately, while plaintiffs’ counsel asserted that the number was more like one in 6000. However, there was no dispute that the plastic surgery community is continuing to do these procedures even as they try to reduce those numbers further. It was further undisputed that the study showed that seven percent of the responding board-certified plastic surgeons had a patient die after a Brazilian Butt Lift due to that cause. Defense counsel also re-called Hughes, who freely testified as an expert witness. Hughes demonstrated the procedures that he had done and explained that the vascular injury attributed to him was impossible. Hughes claimed that he, like all board-certified plastic surgeons, had done several years of training in general and trauma surgery, and was, therefore, familiar with that area of the pelvis. He also testified that the anesthesia record conclusively showed that the first manifestation of problems were associated with oxygen and carbon dioxide, both of which crashed precipitously after the operation. Thus, he claimed that the findings on the record could only be explained by the existence of either a pulmonary blood embolus or pulmonary fat emboli. Hughes further testified that the ineffectiveness of the tPA given in the emergency room in the off-chance that it was a fat embolism showed that it was not a blood embolus, but pulmonary fat emboli (for which tPA does nothing). Furthermore, Hughes testified that the emergency room physician’s initial finding that Vasquez’s abdomen was soft to palpation on admission to the emergency room showed that Vasquez did not have any blood in her abdomen at that time. In addition, he claimed that the fact that all of the emergency room care was directed to a pulmonary etiology further confirmed that Vasquez had pulmonary fat emboli and was 100 percent inconsistent with even a hint of suspicion of a bleed or abdominal trauma. The defense’s Encino-based plastic surgeon, who essentially testified to the same facts as Hughes, testified that the assertion that Hughes had been anywhere near the right internal iliac artery was a physical and anatomic impossibility. Specifically, the expert asserted that Hughes was using a small blunt cannula that would not have allowed him to penetrate through the multiple organs, some of which are quite strong, even when applying very substantial force. The expert also asserted that there should have been significant evidence of damage to multiple organs, as Hughes would have had to press his 9-inch-long cannula approximately seven inches and do so without a sharp edge. In addition, the defense’s expert opined that the change in Vasquez’s vital signs was entirely consistent with a pulmonary obstruction and inconsistent with a bleed., Following the operation, Vasquez suffered a sudden crash in oxygen and carbon dioxide levels, resulting in a very significant drop in her heart rate (bradycardia). CPR was performed for over two hours and she was provided with a tPA. However, Vasquez was ultimately pronounced dead approximately four hours after the operation had concluded. Plaintiffs’ counsel contended that the cause of death was due to a traumatic wound to the right internal iliac artery, which the defense disputed. Vasquez was a long-time social worker, employed by the county of Los Angeles and earning approximately $85,000 annually. At the time of her death, she was 35 years old, unmarried and the mother of two daughters: Desiree Landaverde, 15, and Madison Leon, 3. Madison’s guardian ad litem, her father, testified about how even though Madison was not living with her mother at the time of Vasquez’s death, the family was still close. Desiree also testified about her close relationship with Vasquez and about how Vasquez had season passes to Disneyland with her family. Thus, Vasquez’s daughters sought recovery of wrongful death damages for the loss of their mother. They also sought recovery of approximately $2 million for their loss of Vasquez’s earnings.