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When Leslie Ayala traveled to New York from Philadelphia on June 17 for another round of black-market injections to enhance her buttocks, she expected to leave with more curves, not go into cardiac arrest.

Instead, the 48-year-old suffered an embolism while recovering from the illegal procedure at a friend’s house in the Bronx, dying in spite of being rushed to nearby Jacobi Hospital, reports the New York Daily News.

On Tuesday, the city’s medical examiner ruled Ayala’s death a homicide. A spokeswoman confirmed that Ayala died of “systemic silicone embolism syndrome due to cosmetic silicone injections of buttocks and thighs,” according to the Daily News.

“If not done by a properly trained and licensed physician, silicone injections can cause embolisms that can stop a patient’s heart. Sources said Ayala had received buttocks injections in the past as well,” the outlet added.

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But Ayala’s is just the latest death from illegal injections to be classified a homicide. In June of 2017, two Dallas women pled guilty to murder in relation to the death of Wykesha Reid, who went into cardiac arrest following an unlicensed procedure. In 2015, a Queens, N.Y., doctor was convicted in absentia of homicide, following the death of Maryland native Kelly Mayhew, who suffered symptoms that paralleled Ayala’s. And in May of 2017, Floridian Oneal Ron Morris was sentenced to 10 years in prison for manslaughter after injecting a combination of “combined silicone, mineral oil, Fix-a-Flat tire sealant, cement and Super Glue,” into countless patients, reported the New York Post.

And yet, neither the risks attendant to black market procedures nor the risk of conviction for performing them seems to have stemmed interest in illegal enhancements. As legal butt enhancement procedures often cost several thousands of dollars, women continue to defy the odds by skirting licensed professionals in search of low-priced enhancements, which can be as low as several hundred dollars.

The difference? Aside from the non-sterile environments, unlicensed practitioners and non-FDA-approved injectables, black market injections almost exclusively entail injecting substances like silicone (or in Morris’ case, even more toxic substances) directly into the body—and by extension, the bloodstream, leaving it free to migrate and interact with the immune system and vital organs. This is a stark contrast to implants, which contain silicone or saline within an isolating barrier, maintaining both safety and shape.

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And adverse symptoms from injections administered by anyone but a licensed and accredited doctor may take years to develop, manifesting as allergic reactions, chronic fatigue or severe joint pain.

In Ayala’s case, while the procedure was not her first, that injection of silicone directly into her body was simply too much for her heart to withstand. The investigation into her death remains ongoing, and no arrests have been made, according to police.