Court Opinion

ID: 9391931
Source: CourtListenerOpinion
Date Created: 2023-05-03 18:03:37.360069+00
Date Added: 2024-06-11T17:18:34.411924
License: Public Domain

Filed 5/3/23 Leon v. Hughes CA2/5
   NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS
California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions
not certified for publication or ordered published, except as specified by rule 8.1115(b). This opinion
has not been certified for publication or ordered published for purposes of rule 8.1115.

IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

                         SECOND APPELLATE DISTRICT

                                        DIVISION FIVE

 MADISON LEON, a Minor, etc.,                                     B307344 c/w B308358
 et al.,
                                                                  (Los Angeles County
           Plaintiffs and Appellants,                             Super. Ct. No. BC573903)

           v.                                                     ORDER MODIFYING OPINION,
                                                                  DENYING REHEARING, AND
 KENNETH B. HUGHES,                                               DENYING REQUEST TO
                                                                  PUBLISH OPINION
           Defendant and Respondent.

IT IS ORDERED that the opinion filed in the above-captioned
matter on April 19, 2023, be modified as follows:

       On page 26, in the fourth sentence beginning with “The
matter is remanded for a new trial,” the sentence is replaced with
a new sentence that states: “The matter is remanded for a new
trial on the issue of causation and other proceedings consistent
with our opinion.”

         There is no change in judgment.
    The petition for rehearing filed by respondent Kenneth
Hughes on April 28, 2023, is denied.

     The request to publish opinion is denied.

___________________________________________________________
RUBIN, P. J.                BAKER, J.             MOOR, J.

                               2
Filed 4/19/23 Leon v. Hughes CA2/5 (unmodified opinion)
   NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS
California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions
not certified for publication or ordered published, except as specified by rule 8.1115(b). This opinion
has not been certified for publication or ordered published for purposes of rule 8.1115.

IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

                         SECOND APPELLATE DISTRICT

                                        DIVISION FIVE

 MADISON LEON, a Minor, etc.,                                     B307344 c/w B308358
 et al.,
                                                                  (Los Angeles County
           Plaintiffs and Appellants,                             Super. Ct. No. BC573903)

           v.

 KENNETH B. HUGHES,

           Defendant and Respondent.

      APPEAL from a judgment of the Superior Court of Los
Angeles County, James A. Kaddo, Judge. Reversed and
remanded with direction.
      Law Offices of Michael E. Reznick, Michael E. Reznick and
Lawrence J. Semenza for Plaintiffs and Appellants.
      Cole Pedroza, Kenneth R. Pedroza and Matthew S.
Levinson; Law Offices of Howard A. Kapp and Howard A. Kapp
for Defendant and Respondent.
                   __________________________
       Plaintiffs are Desiree Landaverde, an individual, and
William Leon, as guardian ad litem for Madison Leon, a minor.
Plaintiffs sued Kenneth Hughes, M.D. (defendant), and others,
for the wrongful death of Arleen Vasquez, who was Desiree and
Madison’s mother, alleging defendants’ negligence caused Arleen
Vazquez’s death. After the jury reached a verdict for plaintiffs,
the trial court issued a partial judgment notwithstanding the
verdict (JNOV) in defendant’s favor on the issue of causation. In
the alternative, the trial court granted defendant’s new trial
motion. The court thereafter entered judgment for defendant.
We reverse the JNOV and remand the matter for a new trial on
the issue of causation.
                               FACTS
       “Because this is an appeal from a judgment
notwithstanding the verdict, we state the facts in the light most
favorable to the verdict.” (Flanagan v. Flanagan (2002)
27 Cal.4th 766, 769.)
1.     The Surgery
       On August 4, 2014, defendant performed a cosmetic
surgical procedure known as a Brazilian butt lift on decedent
Vasquez. Dr. Randal May served as the anesthesiologist in the
surgery. The procedure involved the liposuction of fat from
Vasquez’s arms, inner thighs, flanks, and back to her buttocks.1
To access these areas, defendant made incisions to create “port
entries” at the back of Vasquez’s arms above the elbows, at the
left and right groin crease, and at her sacrum. Defendant then
injected a solution into the extraction areas and used different

1     Defendant testified the flank area was part of the lower
back near the kidneys.

                                2
cannulas to suction the fat out of her body and inject it into her
buttocks.2 After defendant harvested the fat from Vasquez’s
arms and thighs, the surgical team flipped Vasquez to lie on her
stomach. Defendant then harvested fat from her flanks. After
the fat was separated from the solution, a “blunt” cannula was
used to inject the fat into the buttocks through the port at the
sacrum.3 Defendant described the procedure in his operative
report this way: “fat was suctioned in fanlike and criss-crossed
fashion to avoid irregularities. Care was taken to feather the
suctioned areas.” Defendant completed the surgery at 11:30 a.m.
and left the operating room. Approximately half an hour later,
Vasquez’s heart rate dropped and she did not respond to
medication. Dr. May, the anesthesiologist, began CPR and staff
called paramedics. When emergency personnel arrived, Vasquez
had no pulse and was not breathing. She was transported to the
hospital, where the emergency room doctor administered “tPA
[tissue plasminogen activator] [¶] . . . [¶] for the possibility of

2     A cannula is a hollow tube-like device with small holes at
the end that defendant used to inject or suction fat. Although
there are many different sizes and designs of cannulas, the
cannulas used in Vasquez’s surgery generally measured a little
over 0.1 inch in diameter (three to four millimeters) and 12
inches long with an additional four- to six-inch handle.
3      Defendant’s operative report indicated he used a
“liposuction” cannula to harvest fat and a “blunt” cannula to
inject the fat. At trial, defendant explained all cannula, no
matter what kind of tip is used, are blunt. One of plaintiffs’
experts testified it was common to use a cannula with a “slightly
sharper and flattened tip” to inject fat but acknowledged he did
not know what type of tip defendant used in Vasquez’s procedure.

                                 3
[pulmonary embolism], although . . . suspect[] . . . may be fat
emboli. However, [there was] no response with tPA.”4 Vasquez
was pronounced dead at the hospital at 1:45 p.m. Her death
certificate identified “exsanguination by traumatic wound of right
internal iliac artery” as the cause of death.5
2.     The Lawsuit
       On February 26, 2015, plaintiffs brought suit against
defendant, Dr. May, George Boris, M.D., and the surgical center
owned by Dr. Boris (where the surgery was performed;
collectively referred to as Boris). Plaintiffs asserted claims for
wrongful death caused by medical malpractice, violation of the
False Advertising Law, violation of the Unfair Business Practices
Act, and violation of the Consumer Legal Remedies Act.
       On July 26, 2017, the trial court granted defendant
Hughes’s motion for summary adjudication as to all causes of
action except for wrongful death. Also prior to trial, the case was
resolved as to the remaining defendants.
       The single wrongful death claim against defendant Hughes
was tried before a jury in 2018. The jury reached a verdict for
defendant, but the trial court (Judge Lisa Hart Cole) granted a
mistrial based on juror misconduct.

4     A pulmonary embolism occurs when a blood clot travels
from a vein in the lower extremity up to the lung. Tissue
plasminogen activator or tPA is used to dissolve blood clots. A fat
embolism occurs when pieces of fat get into the vein and travel to
the lung.

5     Exsanguination is the medical term for when an individual
“bleeds out.”

                                4
       The second trial on plaintiffs’ wrongful death claim (the
trial that is the subject of this appeal) began in January 2020,
before Judge James A. Kaddo. Plaintiffs argued at trial that
Vasquez’s cause of death on her death certificate was correct: she
bled out. Defendant argued she died from a microscopic fat
embolism unrelated to anything he had done.
3.     The Evidence
       Because the issue of substantial evidence to support the
verdict is at the heart of an appeal from a JNOV, we describe in
considerable detail the evidence regarding whether any act or
omission of defendant caused Arleen Vasquez’s death.
       a.     Plaintiffs’ Case
       In support of their exsanguination theory, plaintiffs
presented expert testimony from the deputy medical examiner
who performed the autopsy (Dr. Ajay Panchal), the
anesthesiologist at Vasquez’s surgery (Dr. May), a surgery expert
(Dr. Lloyd Krieger), and a pathology expert (Dr. Michael
Fishbein).
       Dr. Panchal testified he found trauma to the right internal
iliac artery and 2,200 grams of blood in the abdomen.6 Based on
these findings, he concluded the decedent died of exsanguination.
He testified he did not know with certainty whether defendant’s
use of the cannula at the entry portal on Vasquez’s right thigh or
her sacral region caused the traumatic wound to the artery,
“[b]ut it appears to be at least one of those two sites, the sacral

6     Dr. Fishbein estimated that 2,200 cubic centimeters of
blood constituted more than half the blood volume of a woman
the size of Vasquez. One cubic centimeter of blood is equivalent
to one gram of blood.

                                5
site or the right thigh; which, more likely would be the sacral
site.” Dr. Panchal explained that a doctor could access the
internal iliac artery without going through the sacral bone by
going around it. He testified that he asked the photographer at
the medical examiner’s office to take a color photo of the trauma
to the right internal iliac artery. The photograph was admitted
into evidence.
        Dr. May, the anesthesiologist at Vasquez’s surgery,
received permission to attend Vasquez’s autopsy.7 He confirmed
Dr. Panchal pointed out to him a laceration “consistent” with the
right internal iliac artery underneath a hemotoma (a blood clot)
but Dr. May was unsure whether the laceration was to an artery
or a vein.
        Dr. Fishbein, a forensic pathologist who previously had
served as a deputy medical examiner, testified to the cause of
death. He concluded Vasquez died of exsanguination based upon
the amount of blood found in her abdomen. In the course of his
work on the case, Dr. Fishbein met with Dr. Panchal, who
presented him with a specimen from Vasquez’s case — a piece of
tissue that had an artery and a vein running through it. Dr.
Fishbein observed a jagged 2-millimeter tear in the artery.
        Dr. Fishbein disputed defendant’s fat embolus theory,
stating that Dr. Panchal’s findings were consistent with
exsanguination and there was nothing else to explain the death.
He reasoned, “The other important thing is, when someone has
liposuction or when they have CPR, fat can get into the blood
vessels as what we call an incidental finding. So just finding a
little fat in the lung wouldn’t necessarily make that the cause of

7     Portions of Dr. May’s deposition testimony were read into
the record.

                                6
death. Especially here, you have a case where you have a
massive blood loss. [¶] So even if there was a little bit of fat in
the lung, it wouldn’t have been the cause of death, in my
opinion.”
       Dr. Krieger, plaintiffs’ surgery expert, testified to the
standard of care in 2014 for a Brazilian butt lift. He testified it
was mandatory at that time to avoid muscle when harvesting or
injecting fat during a Brazilian butt lift. Injecting fat into the
muscle created “a much higher risk” that some fat could get into
a vessel in the muscle, resulting in a fat embolism, or the cannula
was much more likely to go into a pathway that risked injuring
critical structures because the cannula was much harder to
control when used in muscle rather than fat.
       Dr. Krieger confirmed that defendant’s operative report
indicated he had injected fat into Vasquez’s muscle, which was
below the standard of care. When asked whether defendant
violated the standard of care in any other way, Dr. Krieger
concluded that defendant “did not control the position of the tip of
the cannula, which is why the iliac artery was pierced; internal
iliac.” Dr. Krieger further explained, the artery could have been
cut in one of three ways—when the infusion fluid was injected or
when a cannula was used to pull fat out or put fat in. Dr. Krieger
also explained that when defendant’s report stated that “care was
taken to feather the suctioned areas,” that meant in the medical
community defendant moved the cannula around that area “going
in all directions from the incision, to avoid any of these step-offs.”
From the term “feather,” Dr. Krieger understood defendant
moved the cannula up into the abdomen through the right thigh
port. Dr. Krieger stated he was of the opinion that a traumatic

                                  7
wound to the right internal iliac artery was a substantial factor
in causing Vasquez’s death.
        Also admitted into evidence was a July 2018 “urgent
warning” to surgeons performing Brazilian butt lifts by the Inter-
Society Gluteal Fat Grafting Task Force representing three
“leading clinical plastic surgery societies” and two scientific
societies. The advisory statement was issued “in response to the
alarming number of deaths still occurring from the Brazilian
Butt Lift (BBL).” The statement noted “[t]he cause of mortality is
uniformly fatal fat embolism due to fat entering the venous
circulation associated with injury to the gluteal veins. In every
patient who has died, at autopsy, fat was seen within the gluteal
muscle.” As a result, “fat should never be placed in the muscle.
Fat should only be placed in the subcutaneous tissues.
[Capitalization omitted.]” Because it was easy to enter the
muscle unintentionally, the statement warned surgeons to be
“aware of the cannula tip at every moment; be vigilant about
following the intended trajectory with each stroke and feel the
cannula tip through the skin.” Dr. Krieger explained the 2018
advisement did not represent a change in the standard of care
from 2014, when Vasquez died, but was an “underlining” of
urgency.
        The owner of the surgery center, Dr. Boris, who also
performed Brazilian butt lifts, testified at trial that he initially
believed Vasquez died due to a fat embolus, but had changed his
mind by the time of the second trial, and believed she died from
bleeding out. (Dr. Boris had settled with plaintiffs before the first
trial.)

                                 8
       b.     Defendant’s Case
       Defendant’s theory at trial was that Vasquez died from a
microscopic fat embolus that traveled to her lungs. Defendant
disputed plaintiffs’ theory that he cut into the internal iliac
artery, arguing it was anatomically impossible: A cannula could
not reach the internal iliac artery from the sacrum port because
the sacrum is a large bone that protects the artery and it was
undisputed a drill would be needed to pierce the bone.
Additionally, a cannula could not reach the internal iliac artery
from the right thigh port without leaving a pathway of damage to
the internal structures along the way. Defendant noted that Dr.
Panchal did not identify any damage to any of the organs or
muscles between the thigh port and the internal iliac artery.
Defendant also disputed Dr. Panchal’s observation that Vasquez’s
abdomen was full of blood. He posited the fluid in the abdomen
was mostly comprised of the fluids administered at the hospital.
       Defendant testified in his own defense and described the
procedure he used in Vasquez’s surgery. He also testified that it
was common practice in 2014 for the plastic surgeons he knew to
inject fat into muscle, and that the standard of care changed only
in 2018 when the advisory was issued. Defendant stated it would
have been impossible for a blunt object like a cannula to reach
and pierce the internal iliac artery through the thigh or sacrum
port. He believed Dr. Panchal misidentified the internal iliac
artery; he believed it was “either nothing, . . . or a vein.”
Defendant, however, admitted a patient could bleed out from a
vein. He also acknowledged he could penetrate the muscle using
a cannula if he changed the angle and pushed “so hard.”
       Defendant’s forensic pathologist, Dr. Kevin Whaley,
testified it was impossible for the cannula to breach the sacral

                                9
bone. Dr. Whaley testified access to the internal iliac artery
through the right thigh port would require the cannula to breach
the peritoneum as well as go through several organs such as the
intestine and the uterus.8 He explained there was no notation in
the autopsy report that any of those structures or organs were
damaged and therefore no pathway of damage was seen by Dr.
Panchal, the deputy medical examiner. Dr. Whaley also
emphasized that Dr. Panchal’s testimony from the first trial
(when he testified the injury to the internal iliac artery likely
came through the thigh port) differed from the second trial (when
he testified it likely came through the sacrum).
       Dr. Whaley explained Vasquez’s vital signs were indicative
of a fat embolism because her oxygen levels dropped suddenly
rather than slowly, as they would from a bleed out. He explained
a precipitous drop in oxygen and carbon dioxide levels with
slowed heart rate were the three important markers for fat
embolism. Dr. Whaley questioned whether the fluid found in
Vasquez’s abdomen was all blood. He posited that it mostly
contained a large amount of the fluid that was administered
during the emergency treatment. He testified Vasquez’s
abdomen would have been tense and distended if it had been full
of blood when she arrived at the emergency room but that the
emergency room doctor palpated or pressed against her abdomen
and observed it was soft.
       Dr. Mark Mofid, a plastic surgeon, testified about the
standard of care in 2014 for Brazilian butt lift surgery. Dr. Mofid

8     Dr. Fishbein explained the peritoneum was “sort of like a
layer of saran wrap that surrounds your body cavity” and “if fluid
accumulates or something gets in there, it can fill up. So
anything in that saran wrap layer is called peritoneal.”

                                10
authored a 2017 article bringing to light the risks associated with
injecting fat into muscle rather than into subcutaneous fat. In
support of his article, he conducted a nationwide survey of plastic
surgeons. He affirmed that prior to 2018, 90 to 100 percent of
plastic surgeons would have made intramuscular injections in a
Brazilian butt lift and that “it’s absolutely absurd” to assert the
standard of care was otherwise in 2014.
4.     JNOV
       The jury entered a verdict for plaintiffs, finding defendant
was negligent in his treatment of Vasquez and that his
negligence was a substantial factor in causing her death. The
jury found plaintiffs suffered past economic loss of $231,292,
future economic loss of $784,942, and future nonecomonic loss of
$3 million.9
       Defendant moved for JNOV on the ground there was no
substantial evidence to support the verdict. In the alternative, he
moved for new trial on the grounds of insufficient evidence,
excessive damages, and attorney misconduct. By order dated
July 1, 2020, the trial court rejected defendant’s contention that
there was insufficient evidence to support a finding of negligent
conduct, but granted partial JNOV on the issue of causation. It
explained plaintiffs presented insufficient evidence “illuminating
the connection between the decedent’s purported exsanguination
and the intramuscular fat injection made by the cannula.” The

9     The trial court reduced the award of noneconomic damages
from $3 million to $250,000 pursuant to former Civil Code section
3333.2, subdivision (b), which placed a $250,000 cap on awards
for noneconomic damages in all medical malpractice litigation.
(Yates v. Pollock (1987) 194 Cal.App.3d 195, 200.) The trial court
additionally deducted plaintiffs’ settlement with Dr. Boris
pursuant to Code of Civil Procedure section 877.6.

                                11
court faulted Dr. Panchal for not testifying “that the
intramuscular injection was the cause-in-fact of the nicking of the
internal right iliac artery.”
       The trial court similarly found fault with the remaining
plaintiffs’ experts’ testimony. As to Dr. Krieger (plaintiffs’
surgery expert), the court found lacking his testimony that
defendant “did not control the position of the tip of the cannula,
which is why the iliac artery was pierced” and that the trauma to
the artery was a substantial factor in causing Vasquez’s death.
According to the court, “this does not assist the jury in
determining whether the use of the intramuscular injection was a
cause in fact of the injury.”
       The court also disregarded Dr. Fishbein’s (plaintiffs’
pathologist) testimony that Vasquez died from bleeding out based
on the amount of blood found in her abdomen and that there was
no other explanation for her death. Again, the court concluded
Dr. Fishbein’s testimony failed to include additional evidence
that it was more likely than not that the intramuscular injection
with the cannula was a cause-in-fact of the purported
exsanguination. The court concluded “none of [p]laintiffs’
experts’ testimony on causation contained a reasoned explanation
connecting the exsanguination to the intramuscular fat
injection . . . nor could they testify to such to a reasonable medical
probability.” As a result, the court found plaintiffs’ expert
testimony “did not assist the jury in determining whether it was
more probable than not that the cannula intramuscular injection
of fat traumatized the right internal iliac artery and caused the
decedent to bleed out.” The court then found that Vasquez’s
vitals precluded plaintiffs’ bleed-out theory.

                                 12
       Given its ruling on the JNOV motion, the trial court
initially concluded defendant’s new trial motion was moot. It
nevertheless addressed in detail the grounds for granting a new
trial motion. It noted that had the JNOV not been granted, the
motion for new trial would have been. On July 8, 2020, the trial
court entered an amended order granting defendant’s motion for
new trial in the alternative on the same grounds as set out in the
July 1, 2020 order. The court entered judgment in favor of
defendant on July 29, 2020. Plaintiffs timely appealed. The
Notice of Appeal stated the appeal was from the judgment and
the July 1, 2020 and July 8, 2020 orders. (Code Civ. Proc., § 04.1)
       On August 12, 2020, defendant filed his memorandum of
costs, seeking, among other costs, court reporter fees. Plaintiffs
moved to tax costs, particularly the reporter fees. The trial court
denied plaintiffs’ motion “on legal and practical grounds.” It
reasoned, “There is case law to support an award of the costs
submitted by defendant. As to the court reporter fees, the court
reporter is beneficial to creating a record which would be
impossible without that aid, and therefore motion to strike court
reporter fees is denied on practical grounds.” Plaintiffs filed a
notice of appeal from the costs order. We consolidated the
appeals.10
                            DISCUSSION
       Plaintiffs contend the trial court ignored the substantial
evidence supporting the jury’s verdict and erroneously granted

10   Defendant filed a protective cross-appeal but indicated
during briefing that he would not pursue it.

                                13
JNOV.11 We agree that substantial evidence supports the verdict
and reverse the JNOV. In light of our reversal, the award of
costs to defendant must also be reversed since he is no longer a
prevailing party as identified under Code of Civil Procedure
section 1032, subdivision (a)(4).12 Reversal of the JNOV does not

11     Defendant asserts plaintiffs have forfeited their challenge
to the JNOV because they failed to include the JNOV motion,
opposition, and reply briefs in the record on appeal. We decline
to find forfeiture on this basis. On an appeal from JNOV, we use
the same standard the trial court used in ruling on the motion —
whether substantial evidence supports the jury’s verdict. (Pacific
Corporate Group Holdings, LLC v. Keck (2014) 232 Cal.App.4th
294, 309 (Keck).) Here, the record contains the entire reporter’s
transcript for the second trial and relevant admitted trial
exhibits. The trial court’s order granting JNOV also extensively
describes the parties’ arguments and evidence. Although the
failure to include the underlying memoranda of points and
authorities is puzzling, plaintiffs have provided an adequate
record for a meaningful review of the claimed errors. (See
Jameson v. Desta (2018) 5 Cal.5th 594, 609 [discussing adequacy
of record and importance of reporter’s transcript on appeal].)

12     In a footnote, plaintiffs assert a number of additional errors
that they claim were mooted by the JNOV order, including that
the court erred when it offset the jury’s damages award with
their settlement with Dr. Boris. Plaintiffs fail to properly
address these assertions of error in their briefs. For the purposes
of this appeal, we treat them as abandoned. (See Holden v. City
of San Diego (2019) 43 Cal.App.5th 404, 419.) While plaintiffs
purport to “reserve the right” to submit a brief on these issues to
this Court in the event we reverse the JNOV, we decline to accept
any supplemental briefs. (Cal. Rules of Court, rule 8.200 [“No
other brief may be filed except with the permission of the

                                 14
mean reinstatement of the jury’s verdict, however. The trial
court in the alternative also granted defendant’s motion for a new
trial. Plaintiffs have failed to meet their burden to demonstrate
the trial court committed reversible error when it granted
defendant’s new trial motion. We therefore remand the matter
for a new trial and related proceedings.
1.     JNOV
       a.    Standard of Review
       “A motion for judgment notwithstanding the verdict may be
granted only if it appears from the evidence, viewed in the light
most favorable to the party securing the verdict, that there is no
substantial evidence in support.” (Sweatman v. Department of
Veterans Affairs (2001) 25 Cal.4th 62, 68.) Our review is the
same; we determine if substantial evidence supported the jury’s
verdict. (Keck, supra, 232 Cal.App.4th at p. 309.) “If such
substantial evidence be found, it is of no consequence that the
trial court believing other evidence, or drawing other reasonable
inferences, might have reached a contrary conclusion.” (Bowers
v. Bernards (1984) 150 Cal.App.3d 870, 874 (original emphasis
omitted); see Pope v. Babick (2014) 229 Cal.App.4th 1238, 1245.)
       b.    Proof of Causation in Wrongful Death Claims
       “ ‘The law is well settled that in a personal injury action
causation must be proven within a reasonable medical
probability based upon competent expert testimony.’ ” (Miranda
v. Bomel Construction Co., Inc. (2010) 187 Cal.App.4th 1326,
1336; see also Bromme v. Pavitt (1992) 5 Cal.App.4th 1487, 1499.)
Causation may be shown by reasonable inferences drawn from
substantial evidence. (Sarti v. Salt Creek Ltd. (2008)

presiding justice . . . .”].) On remand, the trial court may address
additional issues encompassed in our remand.

                                 15
167 Cal.App.4th 1187, 1196; Espinosa v. Little Co. of Mary
Hospital (1995) 31 Cal.App.4th 1304, 1315.)
       A plaintiff must prove that a defendant’s negligence was a
substantial factor in causing her harm. (Bockrath v. Aldrich
Chemical Co. (1999) 21 Cal.4th 71, 79.) “ ‘The substantial factor
standard is a relatively broad one, requiring only that the
contribution of the individual cause be more than negligible or
theoretical.’ [Citation.] Thus, ‘a force which plays only an
“infinitesimal” or “theoretical” part in bringing about injury,
damage, or loss is not a substantial factor’ [citation], but a very
minor force that does cause harm is a substantial factor
[citation]. This rule honors the principle of comparative fault.”
(Ibid.)
       The plaintiff’s expert “need not exclude all other
possibilities before he or she can express an opinion that
defendant’s conduct or product caused the plaintiff’s harm.”
(Cooper v. Takeda Pharmaceuticals American, Inc. (2015)
239 Cal.App.4th 555, 580.) Rather, “the plaintiff must offer an
expert opinion that contains a reasoned explanation illuminating
why the facts have convinced the expert, and therefore should
convince the jury, that it is more probable than not the negligent
act was a cause-in-fact of the plaintiff’s injury.” (Jennings v.
Palomar Pomerado Health Systems, Inc. (2003) 114 Cal.App.4th
1108, 1118 (Jennings).)
       In Jennings, a case on which defendant relies, the trial
court struck the testimony of the plaintiff’s expert medical
witness because the expert failed to provide a reasonable
explanation linking the plaintiff’s injury to the defendants’
negligence. (Jennings, supra, 114 Cal.App.4th at pp. 1119–1121.)
There, the defendants left a ribbon retractor inside the plaintiff’s

                                16
peritoneal cavity after surgery. During the second surgery to
remove the retractor, the defendants observed an abdominal
infection in subcutaneous tissue outside the peritoneal wall. The
subcutaneous infection was separated from the peritoneal cavity
(where the retractor was located) by the peritoneal wall and some
muscles; there were no clinical symptoms suggesting the
retractor caused any infection within the peritoneal cavity.
(Ibid.)
       The Court of Appeal found no error in the trial court’s order
striking the expert’s testimony, concluding that the plaintiff’s
expert “never articulated why or how it was more likely than not
that the bacteria, after multiplying without any clinical
symptoms that ordinarily accompany peritonitis, migrated from
the nidus within the peritoneal cavity through the sutured
peritoneal wall, the transversalis fascia, the muscle group and
the rectus fascia, finally settling into the subcutaneous tissue,
while leaving the peritoneal wall intact and leaving behind no
trail of inflamed or infected tissue evidencing this migration.
Instead, [the expert] substituted a conclusion in place of an
explanation, opining ‘[i]t just sort of makes sense. We have that
ribbon retractor and [it’s] contaminated, he’s infected.’ That
opinion is too conclusory to support a jury verdict on causation.”
(Jennings, supra, 114 Cal.App.4th at p. 1120, fn. omitted.)
       c.     Substantial Evidence Supported the Jury’s Verdict
       The jury in this case could have reasonably inferred from
substantial evidence that either defendant’s injection of fat into
muscle or his lack of control of the cannula was a substantial
cause of the wound to the right internal iliac artery, which
resulted in Vasquez’s death by exsanguination.

                                17
       Plaintiffs’ theory at trial was that defendant breached the
standard of care in two ways: (1) he injected fat into the gluteal
muscle resulting in a loss of control of the cannula; and (2) he
simply did not control the position of the tip of the cannula when
he was harvesting fat or injecting fluid through the right thigh
port. Plaintiffs then linked defendant’s negligence to the wound
to Vasquez’s right internal iliac artery, which resulted in
exsanguination and her death.
       As to the breach in the standard of care, Dr. Krieger
testified as follows:
       “Q And the standard of care suggested strongly not to
inject fat into muscle tissue; correct?
       “A Correct.
       “Q Now, can you describe for the jury all of the ways, if
there are any others, you believe Dr. Hughes violated -- [¶] or can
you tell the jury in what manner you believe, based on your
education, training, experience, and the like, Dr. Hughes did or
did not do to violate the standard of care.
       “A Well, he -- he did not control the position of the tip of
the cannula, which is why the iliac artery was pierced; internal
iliac.
       “Q And that clearly was below the standard of care;
correct, sir?
       “A Correct.”
       The court, in its JNOV ruling, only addressed whether
defendant was negligent by injecting fat into muscle. The record,
however, discloses the plaintiffs’ theory of negligence was not
limited to injection of fat into muscle. Defendant acknowledges
Dr. Krieger believed the standard of care was breached in two
ways: “Dr. Krieger also opined that it was negligent for Dr.

                                18
Hughes to ‘feather’ around the inner thigh access ports. He
opined that Dr. Hughes did not control the position of the tip of
the cannula, which is why the iliac artery was injured.”
       Dr. Krieger then testified the injury to the artery occurred
either “when Dr. Hughes lost control of the tip of cannula when
he was using the cannula either though the groin or through the
top of the buttocks.” According to Dr. Krieger, defendant “did not
control the position of the tip of the cannula, which is why the
iliac artery was pierced; internal iliac” and that the cannula “was
pushed too deep and cut the iliac artery, resulting in what’s
called exsanguination, which is where their blood pools outside of
the blood vessels.”13
       Dr. Krieger also testified defendant lost control of the
cannula when he injected fat into Vasquez’s buttock muscle
because the cannula had to penetrate several layers of protective
tissue. The cannula would be “much more likely to go into a
pathway that is of high risk for injuring critical structures”
because the muscle contained blood vessels. Dr. Krieger
explained, muscle “is much tougher than fat. Fat is fluffy.
Muscle is strong, like in the gym. So to get into the muscle,
you’ve got to push. So you’re at a bad angle [not parallel to the
skin], that’s in an unsafe space, at an unsafe angle, and you’re
forced to push harder. [¶] And just as I only want to go six
inches, oops, I went six and a half. And that’s very, very hard to
control when you are in the muscle rather than staying parallel,
in the fat layer.”
       When asked how defendant could have reached the right
internal iliac artery from the back port, both Dr. Panchal and Dr.

13   This testimony was cited by the trial court in denying
defendant’s earlier motion for nonsuit on causation.

                                19
Krieger responded he could do so without having to drill through
the sacrum bone.
       Dr. Krieger testified that the term “feather” was
understood by the medical community to mean using the cannula
in all directions to ensure even removal of fat. Thus, defendant’s
note that “[c]are was taken to feather the suctioned areas” meant
he used the cannula in the direction of the abdomen from the
thigh port even though he did not harvest fat from the abdomen.
Dr. Krieger also explained the cannula could reach the internal
iliac artery through the right thigh port without damaging
internal organs or other structures along the way: “Well, what
happens is that when someone is under anesthesia, their muscles
are all relaxed. And so they’re actually often paralyzed. And so
that allows the structures that are inside to be what we call
flaccid, to lie loosely. [¶] And so while there are plenty of other
structures in the abdomen, there was a clear path that could
have avoided those structures to get to the internal iliac artery.
[¶] And I think you can really see that in this model, that you
can go from here and get it.” Dr. Fishbein likewise testified there
were organs in the area that could “be pushed aside . . . .”
       Having presented testimony on how the right internal iliac
artery was pierced, plaintiffs established through expert
testimony that Vasquez’s death was caused by exsanguination
resulting from the wound to the artery. Dr. Panchal weighed the
amount of blood found in Vasquez’s body and Dr. Fishbein
testified that 2,200 grams or CC’s of blood constituted more than
half the volume of blood for a woman the size of Vasquez.14 Dr.

14     The jury was free to not credit contrary testimony from Dr.
Whaley, defendant’s expert, that the 2,200 grams included
significant amounts of nonblood fluid.

                                20
Panchal and Dr. Krieger affirmed to a medical certainty that
Vasquez died from exsanguination caused by a traumatic wound
to the right internal iliac artery.
       From this substantial evidence, the jury could reasonably
have inferred that defendant’s deviation from the standard of
care—either by losing control of the tip of the cannula during
liposuction or during injection of fat into the muscle—caused
Vasquez’s death.
       While no expert testified word by word that the injury to
the right internal iliac artery resulted from defendant’s injection
of fat into muscle from the sacrum port or loss of control during
the harvesting of fat through the thigh port, plaintiffs’ witnesses
affirmed the artery was lacerated. We are persuaded that
plaintiffs were not required to pin down the exact mechanism by
which these two acts contributed to Vasquez’s death. Plaintiffs’
experts offered a reasoned explanation why it was more probable
than not one of defendant’s negligent acts was a cause-in-fact of
Vasquez’s death. (Jennings, supra, 114 Cal.App.4th at p. 1118.)
       The expert testimony in this case differs from the Jennings
expert’s conclusion that “ ‘[i]t just sort of makes sense,’ ” while at
the same time providing no explanation as to how the infection
could have spread from a surgical device left inside the peritoneal
wall to outside the sutured peritoneal wall, then through various
internal structures and muscles while leaving no trace of infected
tissue. (Jennings, supra, 114 Cal.App.4th at p. 1120.)
       We are also not persuaded by defendant’s multiple
attempts to reweigh and reargue the evidence. In particular,
defendant faults Dr. Krieger for not knowing the precise length of
the cannula, for contradicting defendant’s testimony that he
never directed the cannula “upward” into the abdomen from the

                                 21
groin crease, and for testifying defendant lost control of the
cannula when he did not testify to any loss of control.15
Defendant further asserts Dr. Panchal’s autopsy was deficient
because he did not perform an analysis of the fluid found in
Vasquez’s abdomen, examine Vasquez’s lungs with a microscope,
or consider Vasquez’s vital signs before determining a cause of
death. Nor was there “undisputed evidence,” as defendant’s
claims, of a fat embolism as the cause of death. “When reviewing
an order granting a judgment notwithstanding the verdict our

15      Defendant characterizes Dr. Krieger’s testimony as
“conjecture” from this exchange:
“Q Okay. So he didn’t go into the abdomen?
“A Well, clearly he cut the artery.
“[¶] . . . [¶]
“Q Okay? Did he say – strike that. [¶] . . . [¶] Do you know of
any actual evidence that he went up, ever?
“A Well, the evidence is the lacerated artery, I guess.”
From this isolated testimony, defendant asserts Dr. Krieger
offered no other evidence or explanation beyond his “guess” that
defendant’s cannula went “up” into the abdomen. Yet, Dr.
Krieger’s immediately preceding testimony was:
“Q When did he say he went up, sir?
“A When he said that he feathered.
“Q So the word – [¶] . . . [¶]--‘feathered,’ to you, means to go up;
is that right?
“A The word ‘feathered’ means that you go -- not to me. The use
of the term, universally, is that you’re going in all directions from
the incision, to avoid any of these step-offs.
“Q Okay. That’s your understanding of the word ‘feathered.’
“A Incorrect. That is the universal usage of the term within the
medical community.”
Taken in context, Dr. Krieger’s testimony regarding the injury
from the thigh port was more than a “guess.”

                                 22
role is not to weigh the evidence, but rather to determine whether
any substantial evidence supported the jury verdict.” (Begnal v.
Canfield & Associates, Inc. (2000) 78 Cal.App.4th 66, 77–78.) We
have described the evidence supporting the jury’s verdict and
conclude the trial court erred in granting the JNOV.
2.     New Trial Order
       The trial court alternatively granted defendant’s new trial
motion on two grounds: it found plaintiffs presented insufficient
evidence of causation and plaintiffs’ attorney committed
misconduct in his rebuttal argument. On appeal, plaintiffs
challenge only the finding that their trial counsel committed
misconduct, but fail to properly cite to the record or pertinent
legal authorities to support their argument.
       Plaintiffs entirely fail to address whether it was error for
the trial court to grant a new trial on the issue of causation. By
their silence, plaintiffs apparently have assumed that JNOV and
new trial orders are subject to the same standard of review on
appeal. Not so. As our Supreme Court has explained in Lane v.
Hughes Aircraft Co. (2000) 22 Cal.4th 405, we apply different
standards of review in considering the JNOV ruling and the new
trial order. In Lane, as here, the trial court granted JNOV and,
alternatively, a motion for new trial based on insufficiency of the
evidence. The new trial order cross-referenced findings the trial
court made in granting the JNOV. (Id. at p. 413.) The appellate
court reversed the JNOV, finding substantial evidence supported
the verdict. The appellate court then determined it did not need
to consider whether the evidentiary record supported the new
trial order since it had analyzed whether sufficient evidence
supported the verdicts with respect to the JNOV. (Id. at p. 411.)
Our high court held the appellate court erred in applying the

                                23
same standard when reviewing the JNOV and new trial order.
(Id. at pp. 415–416.)
       The Lane court explained, “an order granting a new trial
under [Code of Civil Procedure] section 657 ‘must be sustained on
appeal unless the opposing party demonstrates that no
reasonable finder of fact could have found for the movant on [the
trial court’s] theory.’ [Citation.] Moreover, ‘[a]n abuse of
discretion cannot be found in cases in which the evidence is in
conflict and a verdict for the moving party could have been
reached . . . .’ [Citation.] In other words, ‘the presumption of
correctness normally accorded on appeal to the jury’s verdict is
replaced by a presumption in favor of the [new trial] order.’ ”
(Lane, supra, 22 Cal.4th at p. 412.)
       Given this authority, plaintiffs are not free to argue,
essentially, “There was substantial evidence to defeat a JNOV; it
follows there was substantial evidence to defeat the grant of a
new trial.” Unlike a court considering a JNOV motion, the court
ruling on a new trial motion sits in an entirely different chair.
“The powers of a trial court in ruling on a motion for new trial are
plenary. The California Supreme Court has held that the trial
court, in ruling on a motion for new trial, has the power ‘to
disbelieve witnesses, reweigh the evidence, and draw reasonable
inferences therefrom contrary to those of the trier of fact’
[citation], that the court sits as ‘an independent trier of fact’
[citation] and that it must ‘independently assess[] the evidence
supporting the verdict’. ” (Barrese v. Murray (2011)
198 Cal.App.4th 494, 503.)
       We need not review the evidence justifying the trial court’s
decision, sitting as the “13th juror,” to order a new trial because
plaintiffs do not challenge the new trial ruling on appeal. “[I]t is

                                24
a fundamental principle of appellate procedure that a trial court
judgment is ordinarily presumed to be correct and the burden is
on an appellant to demonstrate, on the basis of the record
presented to the appellate court, that the trial court committed
an error that justifies reversal of the judgment.” (Jameson v.
Desta, supra, 5 Cal.5th at pp. 608–609.) We accordingly affirm
the new trial order and remand the matter for a new trial and
other proceedings consistent with our opinion.

                                25
                          DISPOSITION
      The July 1, 2020 order granting partial judgment
notwithstanding the verdict as to the issue of causation is
reversed. The September 17, 2020 order denying plaintiffs’
motion to tax costs is reversed. The July 8, 2020 order granting
the new trial motion is affirmed. The matter is remanded for a
new trial and other proceedings consistent with our opinion. The
parties to bear their own costs on appeal.

                                         RUBIN, P. J.
WE CONCUR:

                 BAKER, J.

                 MOOR, J.

                               26