PHILADELPHIA -- It was death by hypodermic needle.
On March 16, 2009, Elsa Then, an unlicensed cosmetologist, went to the Bronx home of a 44-year-old Dominican woman. She jabbed her client in the thighs and buttocks with a syringe filled with a gel-like silicone, charging $800 a cup.
Some of the silicone entered Fiordaliza Pichardo's bloodstream. She died the next day at a hospital from a blood clot. According to media reports, an autopsy showed that she had 1,400 milligrams of silicone in her lungs.
Ellen Borakove, a spokeswoman for the New York City medical examiner's office, said the death was ruled a homicide because the silicone injections had been administered by "a nonmedical, unlicensed person."
A year after Pichardo's death, Then was charged with involuntary manslaughter. She also was indicted on charges that she recklessly injured another customer, the victim's cousin Cheila Pichardo.
Then has pleaded not guilty.
The case against Then is one of an expanding number of criminal investigations to surface recently against backroom practitioners of silicone injections.
The cases offer a glimpse into the underground world of cosmetic procedures that lured 20-year-old Briton Claudia Seye Aderotimi to a Philadelphia hotel room and her death Feb. 7. No charges have been filed in the case, which is classified as a death investigation, pending further inquiry.
It is a thriving business in cities such as New York, Los Angeles, and Miami, often run by unlicensed operators who use industrial grades of silicone that can cause permanent lumps, infection, skin ulceration and potentially fatal blood clots.
"God only knows where they get it," said Steven M. Marcus, medical director of the New Jersey Poison Information and Education System. "If you think about the silicone at Home Depot, it's not intended to be injected into someone."
Marcus said he started seeing botched silicone injections about 10 years ago, primarily among the transgender population. Men who wanted more feminine features would use silicone injections to get rounded bottoms or bigger breasts.
"There was a time when our emergency department at the University Hospital in Newark was seeing one case every couple of weeks," Marcus said.
One woman who came in with an infection said the practitioner had injected her with a silicone product that was stored in a vat. "That should have given her a hint," he said.
In early 2010, Marcus said, six women presented themselves to emergency rooms in North Jersey with complications from silicone injections. "Everyone put two and two together," he said.
As a result of those cases, the Essex County Prosecutor's Office last November charged a 28-year-old woman from New Brunswick, N.J., with practicing medicine without a license. Anivia Cruz-Dilworth, who works as a plus-size model, has pleaded not guilty.
Peter Sepulveda, an assistant prosecutor in Essex County, said Cruz-Dilworth injected women with a product called Hydrogel, charging them $650 to $1,250 for doses. To seal off injection sites, he said, she used Krazy Glue.
Sepulveda said one hospital treated 13 of Cruz-Dilworth's clients, many complaining of high fevers and hardness under the skin near injection sites. "A few people were in the hospital seven or eight times," he said. "They'd be fine for a week or two, then rushed back to the emergency room."
But he said many women were reluctant to testify to a grand jury, knowing high-profile cases could draw attention to their own desires for bigger bottoms. "They are quite embarrassed to be associated with it," he said.
In New York, where the business attracts many Latinas, federal agencies are working together to address the problem.
Last month, an unlicensed 36-year-old Bronx woman, Whalesca Castillo, was arrested on federal charges that she administered illegal injections of liquid silicone as part of an underground cosmetic business that she ran out of her home.
The U.S. attorney's office in Manhattan, working with agents from the FBI and the Food and Drug Administration's criminal unit, said it would continue to expose and prosecute such operations.
Castillo "put the health of unsuspecting women at risk, all to make a quick buck," Preet Bharara, the U.S. attorney for the Southern District of New York, said in a statement at the time.
Castillo, who owns a nail salon in the Bronx, imported silicone from the Dominican Republic.
According to prosecutors, one client, who paid $1,000 for injections, experienced pain and could not sit up straight. That evening, she awoke with shortness of breath, got out of bed, and fainted. Her boyfriend revived her and called Castillo.
Castillo, according to the complaint, told the woman that a hospital would not help because the procedure was illegal.
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