Opinion issued February 11, 2014




                                       In The

                                 Court of Appeals
                                      For The

                           First District of Texas
                             ————————————
                                 NO. 01-13-00479-CV
                             ———————————
                        ROJAN AMJADI, M.D., Appellant
                                         V.
                         ANA S. MANDUJANO, Appellee


                    On Appeal from the 152nd District Court
                             Harris County, Texas
                       Trial Court Case No. 2012-61345


                           MEMORANDUM OPINION

      In this interlocutory appeal, 1 appellant, Rojan Amjadi, M.D., challenges the

trial court’s order denying his motion to dismiss the health care liability claims 2


1
      See TEX. CIV. PRAC. & REM. CODE ANN. § 51.014(a)(9) (Vernon Supp. 2013).
2
      See id. § 74.001(a)(13).
made against him by appellee, Ana S. Mandujano, in her suit for negligence,

fraudulent misrepresentation, and, in the alternative, lack of informed consent and

violations of the Texas Deceptive Trade Practices Act. 3 In two issues, Amjadi

contends that the trial court erred in denying his motion to dismiss Mandujano’s

claims on the ground that she had failed to timely serve him with a qualified expert

report.4

      We affirm.

                                   Background

      In her original petition filed on October 16, 2012, Mandujano alleges that on

November 18, 2010, Dr. Amjadi performed on her a bilateral mastopexy (breast

lift) and an abdominoplasty (tummy tuck).         She asserts that Amjadi, in his

treatment of her, breached the standard of care of a reasonably prudent plastic

surgeon by:

      1. Failing to properly perform her breast implant [surgery], breast
         lifts, and abdominoplasty;
      2. Failing to monitor her condition;
      3. Failing to treat her condition properly after surgery; and,


3
      See TEX. BUS. & COM. CODE ANN. § 17.41–.926 (Vernon 2011 & Supp. 2013).
4
      See Act of May 18, 2005, 79th Leg., R.S., ch. 635, §§ 1–3, 2005 Tex. Gen. Laws
      1590, 1590, amended by, Act of May 24, 2013, 83rd Leg., R.S., ch. 870, §§ 2, 3,
      2013 Tex. Sess. Law Serv. 2220, 2220 (current version at TEX. CIV. PRAC. & REM.
      CODE §.74.351(a) (Vernon Supp. 2013)). We apply the former version of section
      74.351(a) because Mandujano filed her original petition prior to September 1,
      2013, the effective date the amendments. See id.
                                          2
      4. Failing to provide the medical and nursing care reasonably
         required for her condition.

Mandujano asserts that Amjadi’s breach of the standards of care proximately

caused her pain, severe scarring, disfigurement, implant rupture, infection, mental

anguish, and the need for additional surgery. Amjadi answered the suit with a

general denial.

      On February 11, 2013, Mandujano filed with the district clerk an expert

report authored by Michael F. Kaplan, M.D., F.A.C.S., along with his curriculum

vitae. The same day, she served the expert report on Dr. Amjadi by facsimile

transmission,5 but she did not include in the transmission Kaplan’s curriculum

vitae. In his report, Kaplan notes that he is a licensed plastic surgeon, received his

Medical Doctorate degree in 1960, and has been board certified in plastic surgery

since 1975. He is a Fellow of the American College of Surgeons, a member of a

number of medical organizations, and has served on a variety of hospital

committees. Kaplan, who has been performing bilateral mastopexy and

abdominoplasty procedures since 1974, is “familiar with the required standards of

care of the plastic surgeon, specifically with breast implants, bilateral mastopexy

procedures, [and] abdominoplasty procedures, which are the subject of this

particular case.” He explains that it is “[t]he ordinary standard of care for a

5
      See TEX. R. CIV. P. 21a (allowing service of documents by facsimile); Amaya v.
      Enriquez, 296 S.W.3d 781, 784 (Tex. App.—El Paso 2009, pet. denied) (stating
      that health care liability claim expert report may be served by facsimile).
                                          3
bilateral mastopexy” for a plastic surgeon to place the breasts symmetrically “with

normal nipple/areolar complex centralized on the breast mound.” Further, “[t]he

ordinary standard of care for an abdominoplasty procedure” requires a plastic

surgeon to make an

      [i]ncision . . . after marking the patient in the upright standing position
      just above the pubis hairline extending laterally to just above or below
      the anterior iliac crest, whichever is the patient’s choice. Then the
      skin and subcutaneous tissue is raised, the muscles are repaired and
      removal of excess skin takes place. The placement of the umbilicus is
      then pulled through a new opening on the abdominal wall.

      Dr. Kaplan reviewed Dr. Amjadi’s history, operative report, pre-operative

photographs, and progressive notes concerning Mandujano’s surgery. Kaplan also

reviewed the medical records of “Topcare Medical PA,” a global imaging report

concerning Mandujano, and current photographs taken of her after surgery. Based

on his review, Kaplan, in regard to the bilateral mastopexy, opines that

      [Amjadi] did not meet the standards of care for the following reasons:
         Asymmetric breasts,
         Question that the patient may have a leaky right breast implant[,]
         Hypertrophic painful scarring both on the breasts and the
         abdominoplasty incisions[, and]
         Malposition of the nipple areolar complex as well as what looks to
         be leaving areolar tissue on both of [Mandujano’s] vertical
         incisions[.]
Kaplan explains that Amjadi “failed to place the nipple areolar complex on the

breast mound symmetrically and appears not to have removed all of the areolar

tissue after completing the mastopexy/augmentation.”
                                          4
      In regard to the abdominoplasty, Dr. Kaplan explains that Dr. Amjadi “failed

to place the incision low enough to be concealed by . . . clothing” and “left excess

skin below [Mandujano’s] hypertrophic scar thus not obtaining the maximum

amount of tightness for [her].”     He opines, “in terms of reasonable medical

probability and based on [his] review of the medical records as well as [his]

education, training, and experience, that the treatment provided by Dr. Amjadi was

below the accepted standards of care.”

      On February 25, 2013, Dr. Amjadi moved to dismiss Mandujano’s health

care liability claims, contending that she had failed to timely serve him with a

qualifying expert report.6 Amjadi asserted that Mandujano had failed to serve him

with Dr. Kaplan’s curriculum vitae, and he argued that Kaplan’s report does not

qualify as an expert report because it is “conclusory as to breach of the standard[s]

of care and proximate cause.”

      After the deadline to file her expert report had expired, Mandujano, on

March 1, 2013, served Dr. Amjadi with Dr. Kaplan’s curriculum vitae.          In her

response to Amjadi’s motion to dismiss, Mandujano asserted that she inadvertently

did not include Kaplan’s curriculum vitae when she served Amjadi with Kaplan’s

expert report, and she moved “for an extension to file the expert report and



6
      See Act of May 18, 2005, 79th Leg., R.S., ch. 635, §§ 1–3, 2005 Tex. Gen. Laws
      1590, 1590 (amended 2013).
                                         5
curriculum vitae.” 7   She asserted that “Kaplan’s expert report represents an

objective good faith effort to comply with the definition of an expert report.”

      On March 15, 2013, the trial court held a hearing on Dr. Amjadi’s motion to

dismiss. Although the hearing was not recorded and a written order does not

appear in the record, the parties agree that the trial court granted Mandujano’s

request for a thirty-day extension to file the expert report and curriculum vitae.

However, the parties dispute the basis upon which the trial court granted the

extension. 8

      Dr. Amjadi filed a second motion to dismiss on April 17, 2013. At a hearing

on the motion, Amjadi conceded on the record that his prior objection that

Mandujano had not served him with Dr. Kaplan’s curriculum vitae had been cured.

He argued, however, that her claim still had to be dismissed because, although the

trial court had “previously granted an extension to cure deficiencies in the report,”

she had failed to file a “curative report.” The trial court then explained that it had

not found Kaplan’s expert report to be deficient.         Rather, it concluded that

Kaplan’s report “gave [Amjadi] fair notice of what [the] claims were [and] the

standards of care violated.” Thus, the trial court had given Mandujano “the option

7
      See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c) (Vernon Supp. 2013)
      (providing for one thirty-day extension to cure deficiencies in expert report).
8
      Mandujano argues that the trial court granted the extension because she
      inadvertently did not attach Dr. Kaplan’s curriculum vitae to the report when she
      served it on Dr. Amjadi. Amjadi argues that the trial court granted the extension
      because it found that Kaplan’s expert report was substantively deficient.
                                          6
to supplement that report if she wanted to do so.” The trial court concluded that

although Mandujano had chosen not to supplement Kaplan’s expert report, his

report was adequate. And it denied Amjadi’s motion to dismiss.

                               Standard of Review

      We review a trial court’s decision on a motion to dismiss a health care

liability claim for an abuse of discretion. See Am. Transitional Care Ctrs. of Tex.,

Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex. 2001); Gray v. CHCA Bayshore L.P.,

189 S.W.3d 855, 858 (Tex. App.—Houston [1st Dist.] 2006, no pet.). A trial court

abuses its discretion if it acts in an arbitrary or unreasonable manner without

reference to guiding rules or principles. Jelinek v. Casas, 328 S.W.3d 526, 539

(Tex. 2010). When reviewing matters committed to a trial court’s discretion, we

may not substitute our own judgment for that of the trial court. Bowie Mem’l

Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002). A trial court does not abuse its

discretion merely because it decides a discretionary matter differently than an

appellate court would in a similar circumstance. Harris Cnty. Hosp. Dist. v.

Garrett, 232 S.W.3d 170, 176 (Tex. App.—Houston [1st Dist.] 2007, no pet.).

                          Sufficiency of Expert Report

      In his second issue, Dr. Amjadi argues that the trial court erred in denying

his motion to dismiss Mandujano’s health care liability claims because her expert

report “did not set forth a specific breach of the standard of care” by Amjadi and

                                         7
“does not connect [Amjadi’s] alleged negligence to the damages.” 9 And “to the

extent it addressed any of these elements, it was conclusory and insufficient.”

      A health care liability claimant must timely provide each defendant health

care provider with an expert report. 10 See Gray, 189 S.W.3d at 858. The expert

report must provide a “fair summary” of the expert’s opinions as of the date of the

report regarding the applicable standards of care, the manner in which the care

rendered by the health care provider failed to meet the standards, and the causal

relationship between that failure and the injury, harm, or damages claimed. See

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6) (Vernon Supp. 2013).

      If a defendant files a motion to dismiss challenging the adequacy of the

claimant’s expert report, a trial court shall grant the motion to dismiss only if it

appears to the court, after a hearing, that the report does not represent an objective

good faith effort to comply with the definition of an expert report. Id. § 74.351(l);

Scoresby v. Santillan, 346 S.W.3d 546, 554–56 (Tex. 2011). In setting out the

expert’s opinions, the report must provide enough information to fulfill two

9
      Although Dr. Amjadi argues on appeal that Dr. Kaplan’s statement of the standard
      of care is deficient, Amjadi did not raise this issue in the trial court in his motion
      to dismiss. Accordingly, the issue is not preserved for review on appeal. See TEX.
      R. APP. P. 33.1. Further, Amjadi did not argue in the trial court and does not argue
      on appeal that Kaplan’s report is deficient with regard to Mandujano’s claim of
      fraudulent misrepresentation or her alternative claims of lack of informed consent
      and violations of the Texas Deceptive Trade Practices Act. Thus, the issue on
      appeal is confined to Mandujano’s negligence claim.
10
      See Act of May 18, 2005, 79th Leg., R.S., ch. 635, §§ 1–3, 2005 Tex. Gen. Laws
      1590, 1590 (amended 2013).
                                            8
purposes: (1) it must inform the defendant of the specific conduct the plaintiff has

called into question and (2) it must provide a basis for the trial court to conclude

that the claims have merit. Scoresby, 346 S.W.3d at 556 (citing Palacios, 46

S.W.3d at 879).

Breach of the Standards of Care

      Dr. Amjadi first argues that Dr. Kaplan’s report is deficient as to the element

of breach because he “simply concludes that the standard[s] of care [were] not met

due to the results of surgery, without saying that [Amjadi] was negligent in causing

those results.” He asserts that “the report does not state what [he] should have

done differently.”

      “Identifying the standard of care in a health care liability claim is critical:

whether a defendant breached his or her duty to a patient cannot be determined

absent specific information about what the defendant should have done

differently.” Palacios, 46 S.W.3d at 880. As stated, an expert report must provide

a “fair summary” of the expert’s opinion regarding the applicable standards of care

and the manner in which the care rendered by the physician or health care provider

failed to meet the standards.       See TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.351(r)(6). “While a ‘fair summary’ is something less than a full statement of

the applicable standard of care and how it was breached,” it “must set out what

care was expected, but not given.” Palacios, 46 S.W.3d at 880.

                                         9
      In his report, Dr. Kaplan explains that “[t]he ordinary standard of care for a

bilateral mastopexy” is for a plastic surgeon to place breasts symmetrically, with

normal nipple/areolar complex centralized on the breast mound.” Further, “[t]he

ordinary standard of care for an abdominoplasty procedure” requires a plastic

surgeon to make an

      Incision . . . after marking the patient in the upright standing position
      just above the pubis hairline extending laterally to just above or below
      the anterior iliac crest, whichever is the patient’s choice. Then the
      skin and subcutaneous tissue is raised, the muscles are repaired and
      removal of excess skin takes place. The placement of the umbilicus is
      then pulled through a new opening on the abdominal wall.

Thus, Kaplan clearly identifies the pertinent standards of care for a bilateral

mastopexy and an abdominoplasty.

      Dr. Kaplan opines that “[Dr. Amjadi] did not meet the standard of care” for

a bilateral mastopexy because he “failed to place the nipple areolar complex on the

breast mound symmetrically.” Regarding the abdominoplasty, Kaplan explains

that Amjadi “failed to place the incision low enough to be concealed” by clothing

and “left excess skin.” He further opines that, “in terms of reasonable medical

probability and based on [his] review of the medical records as well as [his]

education, training, and experience, that the treatment provided by Dr. Amjadi was

below the accepted standards of care.”

      Dr. Amjadi asserts that Dr. Kaplan’s report is like “the one declared

inadequate” in Shaw v. BMW Healthcare, 100 S.W.3d 8 (Tex. App.—Tyler 2002,
                                         10
pet. denied). In Shaw, however, the expert merely opined that the injection of

sedatives “contributed to [the patient’s] mental deterioration and may have

indirectly contributed to his death,” the injection was an “excessive dosage,” and

the expert “would have started him off on a much lower dose.” Id. at 12–13. The

court concluded, and the plaintiffs conceded, that the expert report “did not

delineate any standards of care that should have been followed.” Id. at 13. Here,

unlike the expert in Shaw, Kaplan identifies the pertinent standards of care that

Amjadi should have followed.

      Dr. Amjadi also asserts that Dr. Kaplan “opines that he believes the

treatment by Dr. Amjadi was below the standard of care, but he never discusses

how or why that is so,” citing Villa v. Hargrove, 110 S.W.3d 74 (Tex. App.—San

Antonio 2003, pet. denied). In Villa, however, the expert report failed to “iterate

the applicable standard of care,” did not “describe the procedures that should be

followed,” and failed “to describe [the patient’s] condition at all.” Id. at 78–79. In

contrast, Kaplan’s report describes the procedures that should have been followed

and describes Mandujano’s condition.

      The trial court could have reasonably concluded that Dr. Kaplan’s report

represents a “good faith effort” to inform Dr. Amjadi of the specific conduct called

into question, the standards of care that should have been followed, and what he

should have done differently. See Palacios, 46 S.W.3d at 880. Accordingly, we

                                         11
hold that the trial court did not err in denying Amjadi’s motion to dismiss

Mandujano’s health care liability claims on the ground that Kaplan’s expert report

does not identify any breaches of the standards of care.

Causation

      Dr. Amjadi also argues that Dr. Kaplan “does not state in his report that any

alleged act or omission . . . proximately caused [Mandujano’s’] alleged injuries or

damages” because Kaplan “simply concludes that [Mandujano] had a less than

optimal result from surgery.” Amjadi asserts that Kaplan fails to “explain how

[his] alleged negligence caused those results” and “mentions problems that may (or

may not) . . . have been present before surgery.”

      An expert report must provide a fair summary of the expert’s opinions

regarding the causal relationship between the failure of the health care provider to

provide care in accord with the pertinent standard of care and the injury, harm, or

damages claimed. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6). “No

particular words or formality are required [in the expert report], but bare

conclusions will not suffice.” Scoresby, 346 S.W.3d at 556. The expert must

provide some basis that an act or omission of a defendant proximately caused

injury. Wright, 79 S.W.3d at 53. In assessing the sufficiency of the report, a trial

court may not draw inferences; instead, it must exclusively rely upon the

information contained within the four corners of the report. Id. at 52; see also

                                         12
Granbury Minor Emergency Clinic v. Thiel, 296 S.W.3d 261, 265 (Tex. App.—

Fort Worth 2009, no pet.) (noting that nothing in section 74.351 prohibits experts,

as opposed to courts, from making inferences based on medical history, citing TEX.

R. EVID. 705 (providing that expert may testify in terms of opinions and

inferences)).

      Here, Dr. Kaplan, in his report, states that, in forming his opinions, he

reviewed Dr. Amjadi’s pre-operative photographs of Mandujano, as well as his

historical, operative, and progressive notes.     Kaplan also reviewed a global

imaging report and photographs taken of Mandujano after the surgery. A causal

relationship between Amjadi’s failure to adhere to the standards of care in

performing the surgical procedures and the resulting injuries to Mandujano is

indicated by Kaplan’s statements that Amjadi, in regard to the standards of care,

failed to symmetrically place the nipple areolar complexes and remove excess

areolar tissue, and Mandujano now has “asymmetric breasts,” “malposition of the

nipple areolar complex,” and “areolar tissue” left “on both of her vertical

incisions.” Further, a causal relationship between Amjadi’s failure to adhere to the

standards of care in performing the surgical procedures and the resulting injuries to

Mandujano is indicated by Kaplan’s statements that Amjadi failed to adhere to the

standards of care in performing the mastopexy and abdominoplasty procedures,




                                         13
and Mandujano now has “hypertrophic painful scarring on both breasts and the

abdominoplasty incisions.”

      Although, as Dr. Amjadi asserts, Dr. Kaplan does not use the term

“causation,” “magic words” are not required.         See Wright, 79 S.W.3d at 53.

Kaplan must merely provide “some basis” that an act or omission by Amjadi

proximately caused Mandujano’s injuries. See id. Here, Kaplan’s report describes

Amjadi’s specific conduct and informs him of the behavior in question, and it

allowed the trial court to determine whether Mandujano’s allegations have merit.

See Scoresby, 346 S.W.3d at 555–56 (citing Palacios, 46 S.W.3d at 879).

      In support of his assertion that Dr. Kaplan has done nothing more than say

“injuries occurred after surgery without saying how or why,” Dr. Amjadi relies on

Windsor v. Maxwell, 121 S.W.3d 42 (Tex. App.—Fort Worth 2003, pet. denied).

In Windsor, the court emphasized that an expert report is sufficient if it contains

information summarizing and explaining the causal relationship between a doctor’s

failure to meet the applicable standards of care and the plaintiff’s injury. Id. at 47–

48 (citing Wright, 79 S.W.3d at 53). There, however, “the closest [the expert]

came to voicing an opinion on the issue of causation is contained in one sentence

of the report: ‘[t]he patient has reported that consent was withdrawn to the

procedure and that the procedure continued despite such withdrawal of consent,

with subsequent infarction documented above.’” Id. at 48. The court concluded

                                          14
that the trial court acted within its discretion when it concluded that the expert

report was deficient as to the causation element. Id. In contrast, Dr. Kaplan’s

report contains information summarizing and explaining the causal relationship

between Dr. Amjadi’s failure to meet the applicable standards of care and

Mandujano’s injury.

      The trial court could have reasonably concluded that Dr. Kaplan’s report

represents a “good faith effort” to inform Dr. Amjadi of the causal relationship

between his failure to provide care in accord with the pertinent standards of care

and the injury, harm, or damages claimed. See Palacios, 46 S.W.3d at 879; Kelly

v. Rendon, 255 S.W.3d 665, 679 (Tex. App.—Houston [14th Dist.] 2008, no pet.)

(emphasizing that expert reports “are simply a preliminary method to show a

plaintiff has a viable cause of action that is not frivolous or without expert

support”). When reviewing matters committed to the trial court’s discretion, we

may not substitute our own judgment for that of the trial court. Wright, 79 S.W.3d

at 52. Accordingly, we hold that the trial court did not err in denying Amjadi’s

motion to dismiss Mandujano’s health care liability claims on the ground that

Kaplan’s expert report does not adequately address the element of causation.

      We overrule Dr. Amjadi’s second issue.




                                        15
                                Extension of Time

      In his first issue, Dr. Amjadi argues that the trial court erred in denying his

motion to dismiss because, after the trial court granted Mandujano’s motion for

extension of time to file a qualifying report, she failed to file a “curative expert

report.” Having concluded that Dr. Kaplan’s expert report is sufficient, we do not

reach this issue.   Moreover, the record shows that the trial court expressly

concluded that Dr. Kaplan’s expert report is adequate and an amended expert

report was not required.

                                    Conclusion

      We affirm the order of the trial court.




                                                Terry Jennings
                                                Justice

Panel consists of Justices Jennings, Sharp, and Brown.




                                         16
