When diamond-trading billionaire Ehud Arye Laniado walked into a posh clinic on the banks of the Champs-Elysées to get his penis enlarged last Saturday, he had no idea it would cost him his life.

The 65-year-old tycoon passed away after suffering a heart attack in the middle of the operation,Fox News reports.

Laniado’s story is tragic. But it doesn’t mean penis augmentation is unsafe, according to New York-based plastic surgeon Norman Rowe.

“[Laniado’s death] had zero to do with the procedure,” Rowe, who wasn’t involved in Laniado’s case, told The Daily Beast. “This was an anesthetic death.”

According to Rowe, Laniado may have opted for a couple of different penis enlargement procedures, including surgical lengthening (which involves cutting a ligament at the base of the penis) or filler injections.

In the U.S., only one silicone implant treatment, Penuma, has gotten approved by the FDA.  Neither the lengthening nor the fillers have been approved by the FDA, but Rowe said the procedures can still be legally performed as “off-label.”

That’s how Rowe has provided filler injections at his clinic for about six years, claiming he performs the procedure on about 20 to 25 men each week. Each injection of hyaluronic acid fillers costs between $250 and $750 and adds girth, Rowe said; patients usually begin with about ten.

Rowe said there are three likely explanations for Laniado’s death, all related to anesthesia.

First, the Paris clinic could have given him general anesthesia, which may have exacerbated pre-existing heart conditions. “If you’re getting general anesthesia and you have an underlying malady in your heart, you will unmask that, and it will show itself,” Rowe said.

But Rowe believes that option is extremely unlikely because there’s no reason to put someone under general anesthesia for such a minor procedure.  

The second possibility is that the clinic improperly administered a dose of local anesthesia. Typically, physicians inject general anesthesia into skin and fat. But if the anesthesia was injected into a blood vessel instead, it could have stopped Laniado’s heart.

The third possibility that Rowe thinks is most likely in causing Laniado’s death is an accidental overdose from sedation, a much milder treatment that leaves the patient conscious and breathing. “It could have been the same thing as Michael Jackson—someone could have overdosed you,” Rowe said, referencing the pop star’s death from a type of anesthetic known as Propofol.

While it’s possible that filler could have been injected into a blood vessel and harmed the heart in a similar way, Rowe said, he believes it’s extremely unlikely due to the direction of blood flow and the size and placement of the blood vessels in the penis.

There haven’t been many studies on the safety and efficacy of hyaluronic acid fillers, but initial results have been positive. A 2003 study in The Journal of Impotence Research on 187 men who’d gotten the procedure found “no serious adverse reactions,” and reported that the procedure appeared to be “safe and effective.” A 2011 study in The Journal of Sexual Medicine on 50 patients came to a similar conclusion, finding no serious adverse reactions. The authors went so far as to describe the treatment as “a very effective and safe technique for penile augmentation.”

A spokesperson for the FDA confirmed to The Daily Beast via email that hyaluronic acid fillers have not been approved for use anywhere besides the face. “We don’t recommend using any materials—approved or not approved—for body augmentation,” they said.

Other techniques have faced slightly more criticism. The American Urological Association doesn’t mention hyaluronic acid fillers, but claims that both surgical penile augmentation and fat-based fillers “[have] not been shown to be safe or efficacious.” A fat-based penis filler injection killed a man in Sweden in 2017, when some of the injected fat entered a vein and caused an embolism.

The bottom line? Augmenting the penis is a medical procedure and requires a reputable doctor—and possibly a reputable anesthesiologist. Rowe said he makes sure to bring in an expert if he’s putting a patient under, and advises patients to be sure that their doctor is comfortable with all of the responsibilities they’ll be taking on during the procedure.

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