Women across the world are risking their lives for illegal procedures to make their buttocks bigger, often involving home-improvement materials such as silicone injected by people with no medical training.
Some want to fill out a bikini or a pair of jeans. Others believe a bigger bottom will bring them work as music video models or adult entertainers. Whatever the reason, they are seeking cheaper alternatives to plastic surgery – sometimes with deadly or disfiguring results.
Deaths from illegal buttocks injections have been reported in Alabama, Georgia, Florida, Pennsylvania, Nevada and New York. An interior decorator in Mississippi faces trial in the deaths of two women who were injected at her house.
Though there is little data on the procedures or injuries they cause, doctors and authorities say they are seeing this more often. Online forums used to set up the illegal procedures have attracted thousands of responses.
Very big buttocks have been popular in hip-hop videos for years. But Dionne Stephens, who studies race, gender and sexuality in hip-hop culture at Florida International University, said celebrities such as Jennifer Lopez, Beyonce and Kim Kardashian are popularising the look among an increasing number of women of all races and ethnicities.
For 46-year-old Apryl Michelle Brown, the path to an illegal injection started with people teasing her as a child about having a "pancake butt". Years later, a woman walked into Brown's beauty salon in California and told her she could make her butt bigger with injections.
The following week, she was at the woman's house getting injections.
It wasn't long before the injection sites got hard and painful. Brown eventually began looking for doctors to remove the material, which she learned was an industrial silicone, available at a home improvement store.
After surgery in 2011, a staph infection left her near death. Both hands and feet were amputated. Today, Brown has a website and speaks on the topic, trying to convince others that they are beautiful the way they are.
Despite a lack of data, there's anecdotal evidence that the illegal procedures are becoming more common.
In April 2007, someone posted this question on the website Topix.com: "Is there any truth to this madness about some type of butt injections to make your butt bigger? Someone enlighten me!"
There have been more than 14 000 responses.
Investigators say a Georgia woman who died after getting injections in Mississippi in 2012 used the Internet to find someone to inject her. She woman drove to the home of Tracey Lynn Garner, an interior decorator with no medical training. The cost was ±R15 000.
The woman died of blood clots in her lungs a few days later. There was so much of a "silicone-like" substance in her buttocks that it spilled onto the floor and "all over the place" when a medical examiner cut into her during the autopsy, according to an investigator's testimony.
Garner is charged with murder and has pleaded not guilty. Garner was later charged in the 2010 death of an Alabama woman and also pleaded not guilty to that charge.
Dr John Martin, a plastic surgeon in Florida, said illicit cosmetic procedures have become common. Sometimes multiple people are injected in hotel rooms in "pumping parties".
Some people have silicone injected in their faces, where it can cause protruding, rock-hard nodules, but it's easier to treat than the large amounts injected into the buttocks. It's so difficult to remove very large amounts of silicone from the buttocks that many doctors, including Martin, won't even try.
"When you put in a large amount of silicone, it can drift. If I fill your butt with this huge amount of silicone, it can run down your leg and mean you have to get your leg amputated," Martin said.
It can also cause infections and blood clots. If the needles hit a blood vessel, the silicone can enter the blood stream and work its way to the lungs, Martin said.
What would doctors do?
Doctors won't perform buttocks injections, but they do offer lifts and buttocks implants. Doctors performed more than 3 700 of those legal procedures last year, generating more than $17 million, according to the American Society of Plastic Surgeons.
The average fee for a legal buttocks implant is ±R45 000, according to the organisation.
In a Florida criminal case, Shatarka Nuby paid ±R20 000 for injections at people's homes, according to police reports.
Nuby died on March 17, 2012. She had received the illegal buttocks injection numerous times from 2007 to 2011, authorities say, and died from acute and chronic respiratory failure from the silicone.