Catalán's death Jan. 25 highlights the existence of numerous private health centers that work without authorization in Spain. The lucrative market for cosmetic treatments, which is growing at a rate of 15 percent per year, generated around $788 million in revenues in 2001, according to the Spanish Association of Aesthetic Surgery.

The clinic of Dr. Gerardo Senderowicz, Catalán's physician, was one of them. And the authorities are now trying to ensure people like him do not work without authorization.

The office of the health ombudsman estimates that up to 60 percent of cosmetic surgery centers are illegal or do not meet all the necessary sanitary and technical requirements. In 2001 alone, the institution received almost 900 complaints, most of them from women who were disfigured.

Senderowicz graduated from a university in Buenos Aires, Argentina, and is a member of the medical association of Madrid, but does not hold a license from the Health Ministry to be able to practice as a surgeon. Despite that, he opened the clinic and an office for dental surgery and general practice in the city seven years ago. Among his patients is a fashion model who ended up with a twisted face. The doctor was ordered to pay $130,000 in damages to the model, according to news releases.

After meeting in December with health authorities and medical associations, state ombudsman Enrique Múgica concluded that public administrations of each of Spain's autonomous regions should control the private clinics. Múgica is urging the Health Ministry to clamp down on the lax regulations that have allowed around 2,000 doctors, mostly trained outside of Spain like Senderowicz, to carry out such treatment. Some 600 doctors are licensed in Spain to practice plastic surgery.

Although its legal representatives argue that the Health Ministry had the clinic on its register, Icema clinic was shut immediately after Catalán's death. Senderowicz has not been charged, however.

The Health Department of the regional government has detected another 200 clinics in Madrid it says are suspicious. In Málaga, the local authorities sealed 16 private clinics and discovered irregularities in another 34.

Catalan's death has brought to light the extent of such treatments in Spain, where around 300,000 aesthetic procedures were performed in 2001, according to the Spanish Association of Aesthetic Surgery.

Although additional clinics are opening every year -- offering treatments from breast implants to liposuction -- up to now there has been no tightening of regulations.

In spite of the costs for the patients -- from $1,500 for a cheek enlargement and $2,600 for a rhinoplasty, to $3,600 for stretching and tensing of muscle tissue in the abdomen -- doctors and clinics specializing in aesthetic surgery have flourished in recent years. Liposuction and breast elevations and enlargements are the most popular aesthetic treatments.

The national healthcare system pays for operations such as dermatological treatments for burns, skin reconstruction after an abrasion or breast reparations after cancer therapy, which are deemed to be necessary health treatments. Aesthetic surgery, however, is not included in the public university curricula in Spain, and the doctors who want to specialize in that area are forced to study outside the country. Also, aesthetic surgery costs are not covered by the state because the problems it intends to solve are not considered detrimental to physical health.

It is within the area of aesthetic medicine that licensed plastic surgeons report more people with degrees from outside Spain. That is why Múgica has suggested including aesthetic surgery within plastic surgery's realm, so that the profession can be thoroughly regulated.

In Madrid, the representative of the Health Department, José Ignacio Echániz, said that in the past three years, inspections in clinics have increased 30 percent. The number of inspectors has grown from 28 to 40 for around 2,000 health centers registered in the region.

The ruling Popular Party has submitted a proposal before the Assembly in Madrid to outline a plan in six months that serves to identify those medical activities that should be forbidden.

"The deaths registered in our community as a result of aesthetic surgery have drawn attention to the outstanding boom that the demand for these kind of treatments has experienced, and the proliferation of clinics that undertake these treatments without previous authorization, which makes it impossible to control their technical competence or their abidance to law," said the group's speaker Miguel Angel Villanueva. Consequently, "we need to increment the level of control."