U.S. health officials have put out a warning advising Americans about the risks associated with “ medical tourism” after nearly two dozen women contracted serious infections as a result of undergoing plastic surgery in the Dominican Republic.

A study recently published in the Centers for Disease Control and Prevention’s journal Emerging Infectious Disease outlines a multistate outbreak after 21 women who underwent liposuction, tummy tucks, breast reductions and butt implant procedures at one of five clinics in the Caribbean nation returned with a severe skin infection.