Regulators plan to start by seeking public input on procedures that should be covered by the requirements, Sharfstein said. That could include liposuction and other surgical procedures that require anesthesia, he said.

Plastic surgeons who operate out of offices that are already accredited welcomed the new regulations as a boon to patient safety. For example, Dr. Adam Summers of the Maryland Plastic Surgery Center in Glen Burnie said that facility would not be affected by the regulations because, although the center bills itself as a "medical spa," it is already licensed by the state as an ambulatory surgical center.

Unregulated medspas are "looking to capitalize on the fact that those procedures are relatively easy and safe to do," Summers said. "The issue is, when you've got a medical spa who goes to the next level and starts offering things like liposuction, now you've got an office not set up for operational sterility and a doctor who's potentially not trained in all the nuances of liposuction."

Licensure and accreditation are not required for all medspas because government health care programs Medicare and Medicaid don't pay for cosmetic surgery, but some centers opt to pursue the certifications anyway. The new regulations being proposed by the state would target medspas that don't seek such oversight.

Plastic surgeons and health officials cautioned that any cosmetic procedure involving a scalpel or a laser involves risk, though. Board of Physicians records show a variety of disciplinary actions in recent years involving plastic surgeons and cosmetic procedures.

In one case, Dr. Oscar Ramirez was stripped of his Maryland medical license in 2011 after the deaths of two patients in 2004 and 2005 at his Timonium office, Esthetique Internationale. One of the patients, a 58-year-old woman seeking "body contouring" surgery to remove fat and tighten skin around her stomach and thighs ahead of her son's wedding, spent 101/2 hours under anesthesia for the surgery, according to Board of Physicians documents. Three days later her husband awoke to find her not breathing; her cause of death was determined to be cardiac arrhythmia.

In the other case, a 55-year-old man sought surgery to remove acne scarring and to thin out his cheeks. He spent 121/2 hours under anesthesia, and less than two hours after the surgery died of cardiac arrhythmia.

The Board of Physicians said Ramirez should not have performed the lengthy surgeries in an office setting because of the risk of complications. The facility was accredited by an industry organization, but the board said it didn't meet the accreditation standards because it wasn't inspected annually and because Ramirez lacked any relationships with nearby hospitals that would have allowed him to admit patients in the event of complications.

Ramirez could not be reached for comment, but his lawyer, M. Natalie McSherry of Kramon & Graham PA in Baltimore, said he continues to disagree with the board's decision. Ramirez argues that his care did not cause the deaths and that his facility was indeed accredited, McSherry said.

The board decision was upheld by Baltimore City Circuit Court and the Maryland Court of Special Appeals. Ramirez plans to petition the case to the Maryland Court of Appeals, McSherry said.

In other cases, the board issued cease-and-desist orders to people who were performing procedures including skin tightening and laser hair removal despite lacking medical licenses, sometimes nevertheless referring to themselves as "doctor."

Summers, the Glen Burnie surgeon, was reprimanded in 2011 because employees in his office called a physician assistant "doctor." The woman had been a doctor in Bulgaria but was not acting outside the scope of her authority as a physician assistant, Summers said.

Regulating where procedures can take place may not guarantee such problems will be prevented, but it "makes it less likely there'll be a tragedy," Sharfstein said.

He added, "Patients still need to ask a lot of questions even after we've set up this whole regimen."

Tips for patients

When choosing where to get a procedure, health officials recommend that patients:

•Verify the physician's license at the Maryland Board of Physicians website:

•Visit the facility and ask to see recovery rooms.

•Ask if the facility is equipped to handle emergencies or has relationships with nearby hospitals.

•Ask if it is accredited by an industry association or the state.

•If you are receiving anesthesia, ask what type it is and the recovery time.

•More questions and other information can be found at

Sources: Maryland Department of Health and Mental Hygiene and the Maryland Ambulatory Surgery Facility Consumer Guide