'Black Madam" Padge-Victoria Windslowe conceded that her specialty - buttocks enlargement using injected silicone - was illegal and even dangerous in the wrong hands.
Her hands were the right ones, Windslowe, 43, boasted. She was "the best, the Michelangelo of buttocks injections."
Windslowe's boast is debatable. A Philadelphia Common Pleas Court jury found her guilty Monday of third-degree murder and aggravated assault in the death of one client and the hospitalization of another.
What is certain is that she was not alone in her field.
Although the U.S. Food and Drug Administration banned the injection of silicone for cosmetic purposes in 1991, underground use never stopped.
Today, popular culture in the United States provides added pressure on women considering buttocks enhancement.
A report last month by the American Society of Plastic Surgeons showed a 15 percent increase - to 11,505 procedures - from 2013 to 2014 in the number of people who underwent buttocks enlargement using body-fat injections. Buttocks implants increased 98 percent - 1,863 procedures - and butt lifts increased 44 percent, to 3,505.
The reasons so many elect a procedure performed by someone with little or no medical training in a hotel room or at a "pumping party" in a home go beyond money - although, according to testimony at Windslowe's trial, that is often a factor.
Elective cosmetic surgery can cost $10,000 or more per procedure and is usually not covered by insurance. Windslowe charged from $500 to $2,000 - cash only - for her hotel-room procedures, which some clients said "looked like good quality."
For women in low-paying jobs, the procedure is a quick and cost-efficient way to keep up with the Kardashians.
For strippers and exotic dancers, for whom buttocks size correlates to the size of tips received at gentlemen's clubs, it's a capital investment.
And in the transgender community, it's a way for people used to living life on the outside to speed the difficult transition from a male body to a female one.
Windslowe is Exhibit A. She testified that she was taught to do silicone injections by a New York nurse who did them on her in 1995, when she was in transition from male to female.
"In the transgender world, we don't always do things the conventional way," Windslowe testified. "There is no path for us."
Naiymah Sanchez, codirector of the Philadelphia-based Trans-Health Information Project, agreed.
"Our community relies on black-market injections just as well as they rely on black-market hormones," said Sanchez, who added that plastic surgeons and doctors involved in medical gender transition are "out of reach" for some transgender people for financial, medical, and personal reasons.
"Our trans community has no choice but to rely on other tactics to feel whole and to fit societal standards of what a woman should look like," Sanchez said.
For some, the choice is a deadly one.
Claudia Aderotimi, a 20-year-old aspiring dancer from London, flew to Philadelphia in 2011 for buttocks injections by Windslowe in an airport hotel. Hours later, she was dead in a nearby hospital after the silicone Windslowe had injected went into a vein and traveled through her bloodstream to her liver, heart, lungs, and brain.
Aderotimi's case is not an isolated one:
In March, Brazilian model Andressa Urach, 27, runner-up in that country's "Miss BumBum" contest, was readmitted to a hospital there with an infection from silicone injections in her buttocks. Just weeks earlier, Urach spent a month in intensive care after silicone injected to enhance her thighs began destroying her legs.
A Toronto woman, Marilyn Reid, 50, is to be sentenced this month after pleading guilty to eight counts of aggravated assault for hotel-room buttocks injections between April 2011 and May 2012. All but one of Reid's nine clients were hospitalized with serious health problems, and four almost died.
Trial is set for April 14 for Kasia Rivera, 37, an East Orange, N.J., woman charged with reckless manslaughter and unauthorized practice of medicine in the May 2011 death of Justin Street, 22, after receiving a silicone injection to enlarge his penis.
In January, Oneal Ron Morris, a 33-year-old Miami-area woman, was charged in the death of one woman and injuring numerous others she allegedly injected with silicone and other substances.
Tracey-Lynn Garner, 54, of Jackson, Miss., was sentenced to life in prison in September in the 2012 death of Karima Gordon eight days after she received silicone buttocks injections.
Katya De La Riva, 40, died in January, one month after receiving silicone injections in a Santa Ana, Calif., hotel room. On Feb. 5, Santa Ana police charged Liborio De La Luz Ramos, 44, with voluntary manslaughter and other offenses.
Although silicone implants - bagged silicone liquid - are still used in cosmetic procedures, plastic surgeons who testified at Windslowe's trial were blunt: Injecting silicone is risky and can be deadly.
"The message is, do not do it," said Assistant District Attorney Bridget Kirn, who prosecuted Windslowe. "This is a deadly practice, and silicone is not an injectable substance."
Some of Windslowe's former clients who testified seemed young and naive - more interested in keeping up with their peers than investigating the hazards of injected silicone and whether Windslowe was medically qualified.
Stephanie Matos, 32, a New York hotel desk clerk, said she was fascinated by the idea of enlarging her buttocks but found conventional plastic surgery too expensive.
In 2008, Matos testified, she found Windslowe through the Internet under the heading "Body by Lillian." Soon, Matos, her sister, her sister's friend, and another woman traveled to Philadelphia to meet Windslowe at a hotel. Windslowe called herself a "nurse-practitioner" who had done the procedure hundreds of times, Matos said.
Matos said she took Windslowe at her word and was pleased with the results - until her sister's friend was hospitalized and almost died.
"I didn't know you could die from it," Matos told the jury. "If I knew that, I never would have done it."
Other clients were dancers or strippers, such as Sharnell Saunders, 29, who told the jury that "a bigger butt is money" and said the results her fellow performers got from Windslowe "looked like good quality."
And others, like Windslowe, are transgender people who wanted a more feminine body.
De La Riva, who died in California in January, was transgender. So were Morris, the Florida woman arrested in January, and Garner, the Mississippi woman sentenced to life.
For activists in the transgender community, who often struggle to make reliable, quality health-care available to their constituents, advising transgender people who express interest in silicone injection procedures can be delicate.
Andrew Goodman, a physician and assistant medical director at Mazzoni Center Family and Community Medicine, which serves sexual minorities in Center City, has worked with many transgender patients.
Goodman acknowledged that people in transition from male to female often seek "rapid feminization" - surgical and cometic procedures on the face, breasts and buttocks - for job and social reasons and to avoid harassment.
Goodman said the procedures, with hormone therapy, can often relieve "psychosocial stress."
But because the procedures are usually not covered by insurance, the price is high, and some patients pursue silicone injections from nonmedical providers.
Goodman said such providers often substitute industrial-grade silicone for medical grade and mix it with other solvents to make it easier to inject.
Transgender advocates like Sanchez, however, say that bluntly telling transgender people not to undergo silicone-injection procedures may be counterproductive.
Sanchez said her organization counsels transgender people to "know the person conducting this type of procedure. We do not tell people to avoid so-called 'black market' tactics. This is about reducing their risk of complication, regardless of where they get their silicone or hormones."
Windslowe faces up to 70 years in prison when sentenced in June.