LOS ANGELES - Trained as a gynecologist and reconstructive surgeon, Dr. John Miklos calls himself a "medical tailor," specialising in surgery to reshape a woman's private parts.
The Atlanta surgeon, who has performed gynecological surgery for nearly 20 years, cites cases of patients who say their sexual response improved after vaginoplasty, a procedure to surgically tighten a vagina stretched by childbirth or aging.
"Women come to me and say they don't have the urge to have sex anymore because they don't feel anything," Miklos said. "I guarantee that if a man didn't feel anything, he wouldn't have sex either."
Female genital cosmetic surgery is a small segment of the US plastic surgery market, but it is growing, with thousands of women estimated to undergo such procedures every year.
That growth comes despite a warning from the American College of Obstetricians and Gynecologists (ACOG), in a 2007 notice to member physicians, that strongly questioned the medical validity and safety of female genital cosmetic surgery.
Earlier this year the group debated the trend at its annual meeting in San Diego.
"None of these procedures have proven effectiveness, and there is potential for harm," Dr. Cheryl Iglesia, a Washington, D.C., gynecologist and former ACOG committee member, wrote in an editorial published in the June issue of Obstetrics and Gynecology.
"Women are being misled or are confused about what is normal," she wrote -- and about what constitutes a condition that can actually be helped through treatment.
Critics say the trend is the latest service aimed at women pursuing an impossible ideal of physical perfection, hyped by Internet pornography and advertising by surgeons who may not explain all the risks, such as infections, scarring, pain and the loss of the very sensations some patients seek to enhance.
"Even when women are told of potential complications, like insensitivity of the clitoris ... they still may be unstoppable if they have the notion that they need a younger-looking or more perfect or more desirable vulva," said Harriet Lerner, a psychologist specialising in women's issues.
More than 2,140 US women underwent "vaginal rejuvenation" last year, according to the American Society for Aesthetic Plastic Surgery.
The International Society of Aesthetic Plastic Surgeons put the US total at nearly 5,200 in 2010. Experts note such figures do not include the many procedures done by gynecologists.
ACOG not only points to the risks of genital surgery but also emphasizes that female sexual response is driven by psychological factors rather than genital appearance.
The group has asked its members to be aware of how they might unwittingly influence a patient to consider surgery.
In practices across the country, doctors say more women, from teenagers to those in their late 70s, want to discuss the procedures, which can cost between $2,500 and $12,000 and are usually not covered by insurance.
"I tell every patient you are normal the way you are," said Miklos, who each year performs as many as 180 labiaplasties to cut back the skin flaps surrounding the vaginal opening.
"I would never suggest that they get one. What is the right size of a nose, or a chin? That's up to the individual. It's her right to decide."
From repair to aesthetics
From repair to aesthetics
Corrective gynecological surgery has been available for decades, including procedures to alleviate incontinence or sagging of the vaginal canal after childbirth.
In the 1990s surgeons began offering procedures that promised the improved aesthetics, self-esteem and confidence associated with nose jobs or other plastic surgeries.
"One side was longer than the other side. ... It was something that bothered me," said Kari, a 36-year-old labiaplasty patient of Beverly Hills, California, plastic surgeon Fardad Forouzanpour. (She did not want to give her last name.)
"It makes me more comfortable. I like the way that it looks."
She said her boyfriend was not involved in her decision, but she did "look at a few Playboys here and there."
One patient, who did not want to use her name, said she had surgery because she hated the look of her labia, even though her husband had no problem with her appearance.
Other procedures include creating a new hymen for "revirgination" and "G-spot amplification," which involves injecting the area in the front wall of the vagina with collagen or another filler to enhance sexual gratification.
In some cases, patients may not leave satisfied. One way Miklos seeks clients is by running a website called botchedlabia.com, where women who have already experienced complications can get advice on revisions.
Surgeons say many patients have been influenced by images of the waxed, buffed or surgically altered genitals of porn actresses.
"They see these porn stars who have things done, and they look so nice and clean-cut," said Forouzanpour, who does 15 to 25 labiaplasties a month.
"It is normal to have some extra skin, or some discolouration."
While studies have shown some social advantages to plastic surgery that improves a person's overall appearance in public, like a nose job or face-lift, there is no data showing the benefits of altering one's genitals.
"The ethical question is: How much are you playing on women's insecurities?" Dr. Iglesia said. "Women are getting very much duped into thinking there is a standard look for the vulva."
By all measures, Miklos has thrived on his expertise. Along with partner Dr. Robert Moore, he now has practices in Atlanta, Georgia and Beverly Hills. He says he tries to stay away from procedures with more dubious outcomes.
For example, surgery claiming to enhance the "G-spot," which may play a role in sexual arousal, raises red flags as no controlled studies have been done, or are likely to be done, to show whether it has any effect.
"I don't routinely do them. People ask for them, but I don't want someone to pay US$1,000 (S$1,290) and have high hopes," Miklos said. "People get upset when there is no response."